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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 |