The Medical Record
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| The physician responsible for the care of a hospitalizedbpatient. | Attending physician
🗑
|
||||
| Charting | The process of making written entries about a patient in the medical record.
🗑
|
||||
| Consultation report | A narrative report of an opinion about a patient's condition by a practitioner other that the attending physician.
🗑
|
||||
| Diagnosis | The scientific method of determining and identifying a patient's condition.
🗑
|
||||
| Diagnostic procedure | A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition.
🗑
|
||||
| Discharge summary report | A brief summary of the significant events of a patient's hospitalization.
🗑
|
||||
| Eletronic medical record (EMR) | 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.
🗑
|
||||
| Home health care | The provision of medical and non-medical care in a patient's home or place of residence.
🗑
|
||||
| Informed consent | Consent given by a patient for a medical procedure after being informed of the nature of his or her condition.
🗑
|
||||
| Inpatient | A patient who has been admitted to a hospital for at least one overnight stay.
🗑
|
||||
| Medical impressions | Conclusions drawn by the physician from an interpretation of data.
🗑
|
||||
| Medical record | A written record of the important information regarding a patient
🗑
|
||||
| Medical record format | The way a medical record is organized.
🗑
|
||||
| Objective symptom | A symptom that can be observed by an examiner.
🗑
|
||||
| Paper-based patient record (PPR) | A medical record in paper form.
🗑
|
||||
| Patient | An individual receiving medical care.
🗑
|
||||
| Physical examination | An assessment of each part of the patients body.
🗑
|
||||
| Physical examination report | A report of the objective findings from the physician'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 prospects for a patient's recovery.
🗑
|
||||
| Reverse chronological order | Arranging documents with the most resent at the front and oldest in the back.
🗑
|
||||
| SOAP format | A method of organization for recording progress notes; Subjective data, Objective data, Assessment, & Plan
🗑
|
||||
| Subjective symptom | A symptom that is felt by the patient, but is not observable by an examiner.
🗑
|
||||
| Symptom | Any change in the body or its functioning that indicates the presence od disease.
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
justineentingh
Popular Medical sets