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Chapter 1
bonewit
| Question | Answer |
|---|---|
| Attending physician | Physician responsible for the care of a hospitalized patient. |
| Charting | The process of making written entires about a patient in the medical record. |
| Consultation Report | Narrative report of an opinion about patients condition by a practitioner other than the attending physician. |
| Diagnosis | The scientific method of determining and indentifying a patient's condition. |
| Diagnosis procedure | A procedure performed to assist in the diagnosis, management, or treatmeant of a patient's condition. |
| Discharged summary report | A brief summary of the significant events of a patients hospitalization. |
| Electronic medical record | A medical record that is stored on a computer. |
| Familial | Occurring or affecting members of a family more frequently than would be expected by chance. |
| Health history report | A collection of subjective data about a patient. |
| Informed consent | The consent given by a patients for medical procedure after being informed of the procedure. |
| Inpatient | A patients who has been admitted to the hospital for atleast one overnight stay. |
| Medical impressions | The conclusions reached by the physician from an interpretation of data. |
| Medical Records | A wriiten record of the important information regarding a patient. |
| Objective symptom | A sympton that can be observed by an examiner. |
| Patient | An individual receiving medical care. |
| Physical examination report | A report of the objective finding from the physican;s assessment of each body system. |
| Problem | Any condition that requires further observation, diagnosis, management, or patient education. |
| Prognosis | The probable course and outcome of a disease and the prospect for recovery. |
| Subjective symptom | A symptom felt by the patient but not observed by an examiner. |
| Symptom | Any changes in the body or its functioning indicative that a disease is present. |
| SOAP Format | a method of organization for recording progress notes. |
| reverse chronological order | arrangingg documents with the most recent document on top or in the front |
| physical examination | an assensmentof each part of tge patients body to obtain objective data |
| Paper-based ptient record | A medical record in paper form |
| medical record format | the way a medical record is organized. |
| home health care | the provision od medical and non medical care in a patients home |
Created by:
heathertaylor
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