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Chapter 1 bonwit

The physicain responsibke for the care of the hospitalized patient Attending physician
the process of making written entries about a patient in the medical record charting
the scientific method of determining and indentifying a patients condition diagnosis
a narrative report of an opinion about a patients condition by a pracitioner other than the attending physician consultation report
a procedure performed to assist in the diagnosis management or treatment ot a patients condition diagnostic procedure
a brief summary of the significant events of a patients hospotalization discharge summary report
a medical record that is stored on a computer EMR - electronic medical record
occurruing or affecting members of subjective memebers of a family more frequently than would be expected by chance familial
a collection of subjective data about a patient health history report
the provision of medical and non medical care in a patients home or place of redience home health care
a patient who has been admitted to a hospital for at least one overnight stay inpatient
conclusions drawn by the physicain from an interpretation of data medical impression
a written record of the importance information regarding a patient, including the care of the indicidual 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 a examiner objective symptom
an assessment of each part of the patients body to obtain objective data about the patient that assists in the determining the patients state of health physical examination
a report of the objective findings from the physicains assessment of each body system physical examination report
any condition that requires further observation diagnosis management or patient education problem
the probable course and outcome of a disease and 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 of a section or file reverse chronological order
a method of organization for recording progress notes. the SOAP format includes the following categories: subjetive, objective, assessment, plan SOAP format
a symptom that is felt by the patient but is not observable by an examiner subjective symptom
any change in the body or its functioning that indicated the presence of disease symptom
consent given by a patient for a medical procedure after being informed of the nature of his or her condition. the purpose of the procedure alternative treatment or procedures available the likely out come of the informed consent
a medical record in paper form PPR
individual receiving medical care patient
Created by: Breanneharber