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Bonewit chap 1

Must be completed by all new patients and consists ofdemographic and billing information. The patient registration record.
Is used to determine the patient's general state of health, to arrive at a diagnosis and prescribe treatment, and to observe at a diagnosis and prescribe treatment, and to observe any change in a patient's illness after treatment has been instituted. The Health History
Is a summary of the findings from the physician's assessment of each part of the patient's body. The physicl examination
Consists of detailed information relating to a patient's medications and includes one or more of the folloing categories: prescription medications, over-the-counter (OCT) medications, and medications administered at the medical office. The medication record
Is a narrative report of a specialist's opinion about a patient's condition and is based on a review of the patient's medical record and examination of the patient. The consultation report
Provides medical and nonmedical care in a patient's home or place of residence to minimize the effect of disease or disaility. Home health care
Is a report of the analysis or examination of body speciments. Its purpose is to relay the result of laboratory tests to the physician to assist him or her in diagnosing and treating disease. A laboratory report
Consists of a narrative description and interpretation of diagnostic procedure and includes the following reports; electrocardiogram, Holter monitor, sigmoidoscopy, colonoscopy, spirometry, radiology, and diagnostic imgaging. A diagnostic procedure report
documents the assessments and treatment designed to restore a patient's ability to function, such as physical therapy, occupational therapy, and speech therapy. A therapuetic service report
Are prepared by the attending physicin and include the history and physical examination of a hospitalized patient, operative report, discharge summary report, pathology report, and emergency deparment report. Hospital documents
Is required for all surgical operations and nonroutie diagnostic or therapeutic procedures performed in the medical office. The form must be signed by the patient and provides written evidence that the patient agreed to the procedure(s) listed on the for A consent to treatment form
is required to release information that is not part of medical treatment, payment, and health care operations. A release of medical information form
Is orgainized into sections base on the department, facility, or oter source that generated the information. Each section of a source-oriented record is separated from the others by a chart divider labeled with the title of its respective section. A source-oriented medical record.
Are organized by the patient's specific health problems and include a database, problem list, plan of action for each problem, and progress notes. Progress notes for a POR include four categories: subjective data, obective data, assessment, and plan (SOA The documents in a problem-oriented record (POR)
Consistts of te following cmponents: identification data, chief compaint, present illness, past history, family history, social history, and review ofsystmes. A health history is taken for each new patient, and subbsequent ofice visits (in the form of pr A health history
Is the process of making written entries about a patient in the medical record. The medical record is a legal document, and the information must be charted as completely and accurately as possible, following established charting guidelings. Charting
Update the medical record with new information each time the patient vists or telephones the medical office. Types of progress notes often charted by the medical procedures, administered. medical assistant include patient symptoms, medical procedures, a Prgress notes
a medical record in paper form PPR
an individual receiving medical care. patient
an assessment of each part of the patients body obtain objective data about the patient that assists in deteremining physical examination
a report of the objective finding from the physicains assissement physical examination report
any condition that requires further observation problem
the probable course and outcome of a disease prognosis
arraging documents with the most recent documents on top reverse chronological order
method of organizing for recording progress notes soap format
a symptom felt by the patient bot is not observed subjective symptom
any change in the body symptom
Created by: Breanneharber