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Chapter 1 bonwit
| Question | Answer |
|---|---|
| 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
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