Question | Answer |
The physician responsible for the care of a hospitalized patient | Attending Physician |
The process of making written entries about a patient in the medical record | Charting |
A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician | Consultation Report |
The scientific method of determining and identifying a patient's condition | Diagnosis |
A procedure performed to assist in the diagnosis, management or treatment of a patient's condition | Diagnostic Procedure |
A brief summary of the significant events of a patients hospitalization | Discharge summary report |
A medical record that is stored on a computer | Electronic medical record |
Occurring in or affecting members 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 nonmedical care in a patient's home or place of resident | Home health care |
Consent given by a patient for a medical procedure after he or she has been informed. | Informed consent |
A patient who has been admitted to a hospital for at least one overnight stay | Inpatient |
Conclusion drawn by the physician from an interpretation of data | Medical impressions |
A written record of important information regarding a patient, including the care of that individual and the progress of the patient's condition | Medical Record |
The way a medical record is organized. Two main types are source-oriented and problem-oriented | 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 seeking medical care | Patient |
An assessment of each part of the patient's body to obtain objective data about the patient that assists the physician in determining the patient's state of health | Physical examination |
A report of the objective findings from the physician's 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 the prospects for a patient's recovery | Prognosis |
Arranging documents with the most recent document on top or in front | Reverse chronological order |
A method of organization for recording progress notes. It includes the following categories: Subjective data, objective data, assessment, and plan | SOAP format |
A symptom that is felt by the patient but in not observable by an examiner | Subjective symptom |
Any change in the body or its functioning that indicates the presence of disease | Symptom |