Chapt 1 - Medical Record - Nora Godsey
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Attending Physician | The physician responsible for the care of a hospitalized patient
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| Charting | Process of making written entries about a patient in the medical record
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| Consultation Report | Narrative report of an opinion about a patient's condition by a practitioner other than the attending physician
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| Diagnosis | Scientific method of determining & identifying a patient's condition
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| Discharge Summary Report | Brief summary of the significant events of a patient's hospitalization
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| EMR- Electronic Medical Record | Medical record that is stored on a computer
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| Familial | Occurring in or affecting members of a family more frequently than would be expected by chance
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| Health History Report | Collection of subjective data about a patient
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| Home Health Care | Provision of a medical & nonmedical care in a patients home or place of residence
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| Informed Consent | Patient has been informed of the condition & purpose of procedure, they know the risks involved, other treatments available, outcome, & risks involved with declining or delaying procedure
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| Inpatient | Patient who has been admitted to a hospital for at least one overnight stay
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| Medical Impressions | Conclusions drawn by the physician form an interpretation of data. Other terms for impressions include provisional diagnosis & tentative diagnosis
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| Medical Record | Written record of important information regarding a patient including the care of the individual & the progress of the patient's condition
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| Medical Record Format | The way a medical record is organized; Two main types of medical record formats are the source-oriented record & the problem-oriented record
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| Objective Symptom | Symptom that can be observed by an examiner
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| PPR- Paper-based Patient Record | Medical record in paper form
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| Patient | Individual receiving medical care
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| Physical Examination | Assessment of each body to obtain objective data about the patient that assists in determining the patients health
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| Physical Examination Report | Report of objective findings from the physicians assessment of each body system
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| Problem | Any condition that requires further observation, diagnosis, management, or patient education
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| Prognosis | The probable course & outcome of a disease & the prospects for a patient's recovery
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| Reverse Chronological Order | 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
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| SOAP Format | A method of organization for recording progress notes; includes the following categories: subjective data, objective data, assessment, and plan
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| Subjective Symptom | A symptom that is felt by the patient, but is not observable by an examiner
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| Symptom | Any change in the body or its functioning that indicates the presence of disease
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Created by:
noragodsey
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