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Bonewit Chapter1

The Medical Record

Attending Physician The physician responsible for the care of a hospitalized patient.
Charting The process of making written entries about a patient in the medical record.
Consultation report A narrative report of an opinion about a Practitioner other than the attending physician.
Diagnosis The scientific plan method of determining and identifying a patient's condition.
Diagnostic procedures A procedure to preformed to assist in the diagnosis, management, or treatment of a patient's condition.
Discharge summary report A brief summary of a significant events of a patient's hospitalization.
Electronic medical record (EMR) A medical record that is stored on a computer.
Familial Occurring or affecting members of a family more frequently than would be expected by chance.
Health history report A collection of subjective data about a patient.
Home health care The provision of medical and non-medical care in a patient's home or place of residence.
Informed consent Consent given by a patient for a medical procedure after being informed of the nature of his or her condition.
Inpatient A patient who has been admitted to a hospital for at least one overnight stay.
Medical impressions Conclusions drawn by the physician from an interpretation of data.
Medical record A written record of the important information regarding a patient, including the care of the individual and the progress of the patient's condition.
Medical record format The way a medical record is organized. the two main types of medical records formats are the source-oriented record and the problem-oriented record.
Objective symptoms A symptom that can be observed by an examiner.
Paper-based patient record (PPR) A medical record in paper form.
Patient An individual who is receiving medical care.
Physical examination An assessment of each part of the patients body to obtain objective data about the patients that assist in determining the patients state of health.
Physical examination report A report of the objective findings from the physician assessment of each body system.
Problem Any condition that requires further observation diagnosis, management, or patient education.
Prognosis The probable course of and out come of a disease and the prospects for a patients recovery.
Reverse Chronological order older documents on the bottom of the folder.
SOAP format Subjective data, Objective data,Assessment, and plan.
Subjective plan A symptom that is felt by the patient, but is not observable by an examiner.
Symptom Any change in the body or it's functioning that indicates the presence of disease.
Created by: RyanBreakall