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Bonewit Chapt 1

The Medical Record Logan Greene

TermDefinition
Attending Physician The physician responsible for the care of a hospitalized patient.
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 than 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.
Electronic Medical Record (EMR) A medical record that is stored on a computer.
Familial Occurring in 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.
Informed Consent Consent given by a patient for a medical procedure after he/she has been informed of the nature of his/her condition and the required information including the outcome of the procedure, and the risks involved with the declining or delaying the procedure.
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. Other terms for impressions include provisional diagnosis and tentative diagnosis.
Medical Record A written record of important information regarding a patient, including the care of that individual and the progress of that patient's condition.
Medical Record Format 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.
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 patient's body to obtain objective data about the patient that assist the physician in determining the patient's state of health.
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 recent document on top or in the front, which means the oldest document is on the bottom or at the back of a section or file.
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 of disease.
Home Health Care The provision of medical and nonmedical care in a patient's home or place of residence.
Created by: logangreene
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