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chapter 2 flash card
flash cards2
Term | Definition |
---|---|
chief complaint | main reason for a patients visit |
"pre-op" | before surgery |
radiology report | explains the reason for ordering a radiologic image, how the image was performed, what was seen on the image, and the reviewing radiologist's assessment |
"ER" | emergency room |
discharge summery note | a note that details when and why a patient was admitted |
the only note that DOES NOT follow the SOAP format | prescription |
admission summary | documents the admission of a patient to the hospital |
"L&D" | labor and delivery |
"febrile" | to have a fever |
"EHR" | electronic health records |