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bonewit chap 1
end of chapter 1 vocab
| Question | Answer |
|---|---|
| the physician responsible for the care of a hospitalized patient. | attending physician |
| the process of making written entries about a patient in the medical record. | Charting |
| a narrative report of an opinion about a patient's condition by a practitioner other than the attending physician | Consultation Report |
| the scientific method of determining and identifying a patient's condition. | Diagnosis |
| a procedure performed to assist in the diagnosis, management, or treatment of a patient's condition. | Diagnostic Procedure |
| A breif summary of the significant events of a patient's hospitalization | Discharge summary report |
| a medicial record that is stored on a computer | Electronic Medical Record |
| Occuring or affecting members of a family more frequently than would be expected by chance. | Familiar |
| A collection of subjective data about a patient. | health history report |
| the provision of medical and non-medical care in a patient's home or place of residence. | Home health care |
| Consent given by a patient for a medical procedure after being informed of the nature of his or her condition. | Informed Consent |
| a patient who has been admitted to a hospital for at least one overnight stay. | Inpatient |
| conclusions drawn by the physician from an interpretation of data. | Medical impressions |
| A written record of the important information regarding a patient, including the care of that individual and the progress of the patient's conditon. | Medical Record |
| The way a medical record is organized. The two main types of medical record formats are the source-oriented record and the problem-oriented record. | Medical record format |
| A symptom that can be observed by an examiner | Objective Symptom |
| a medical record in paper format | PPR |
| an individual recieving medical care | Patient |
| an assesment of each part of the patient's body to obtain objective data about the patient that assists in determining the patient's state of health | Physical examination |
| a report of the objective findings from the physician's assessment of each body system. | Physical examination report |
| any condition that requires further observation, diagnosis, management, or patient education | Problem |
| the probable course and outcome of a disease and the prspects for a patient's recovery | Prognosis |
| arranging documents with the most recent document on top or in the front, which means that the oldest document is on the bottom or at the back of a section or file. | Reverse Chronological Order |
| a method of organization for recording progress notes. The SOAP format includes the following categories: subjective data, objective data, assessment, and plan | SOAP format |
| a symptom that is felt by the patient, but is not observable by an examiner | subjective symptom |
| any change in the body or its functioning that indicates the prescence of disease. | Symptom |
Created by:
troyschultz
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