Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Bonewit Chapter 1
The Medical Record
| Question | Answer |
|---|---|
| The physician responsible for the care of a hospitalizd 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 patients condition by a practioner other than the attenting physician | consultation report |
| the scientific method of determining and identifying a patients condition | diagnosis |
| a procedure performed to assist in the diagnosis, management, or treatment of a patients condition. | diagnostic procedure |
| a brief summary of the significant events of a patients hospitalization | discharge summary |
| a medical record that is stored on a computer | electronic medical record (EMR) |
| occuring or affecting members of a family more frequently then would be expected by chance | familial |
| a collection of subjective data about a patient | health history report |
| the prousion of medical and non-medical care in a patients home or place of residence. | home health care |
| consent given by a patient for a medical procedure after being informed of the nature of the condition,the purpose of the procedure,and explanation of risk involved,other treatment or procedure available,the prognosis,and the risk involved in declining it | 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 infromation regarding a patient including the care of that individual and the progress of the patients condition | medical record |
| the way a medical record is organized. The two main types of medical record format 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 form | paper-based patient record (PPR) |
| an individual receiving medical care | patient |
| an assessment of each part of the patients body to obtain objective data about the patient taht assists in determining the patients state of health | physical examination |
| a report of the objective findings from the physicians assessment of each body system | physical examination report |
| any condition that requires further observation, diagnosis, management, or patiend education. | problem |
| the probable course and outcome of a disease and the prospects for a patients recovery | prognosis |
| arranging documents with the most recent document on top or in the front, which means that the oldest document is on the botton or at the back of a section or file. | reverse chronological order |
| a method of organization for recording progress notes. The SOAP formant includes the following catefories: subjective data, objective data, assessment, and plan | SOAP format |
| a symptom that is flet by the patient, but is not observable by an examiner. | subjective symptom |
| any change in the body or its functioning that indicates the presence of disease | symptom |
Created by:
AlyssaSearls
Popular Medical sets