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terminology review 1
chapter one
| Question | Answer |
|---|---|
| the physician responsible for the care of hospitalized patients | 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 practitioner other than the attending physicians | 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 patient hospitalization | discharge summary report |
| a medical record that is stored on a computer | electronic medical record (EMR) |
| occurring or affecting members of a family more fequently than would be expected by chance. | familial |
| a collection of subjective data about patient | health history report |
| the provision 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 | informed consent |
| a patient who has been admitted to the hospitalfor at least one overnight stay | impatient |
| conclusions drawn by the physician from an interpretation of date. other terms for impressions include provisional diagnosis and tentative diagnosis | medical impressions |
| a written record of the important information regarding the 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 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 form | paper based patient record (ppr) |
| an individual receiving medical care | patient |
| a report of the objective findings from the physicians assessment of each body system | physical examination report |
| any condition that requiers furthur observation diagnosis, management, or patient 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 bottom or at the back off 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 the examiner. | subjective symptom |
| any change in the body or its functioning that indicated the presence of disease | symptom |
| an assessment of each part of the patients body to obtain objective data about the patients that assists in determing the patient state of health | physical examination |
Created by:
darciascearse
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