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terminology review 1

chapter one

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