Ch 2: Terms

Question 1

Abstracting

Answer 1

Extracting data from the health record

Question 2

Admission Diagnosis

Answer 2

Diagnosis that brings the patient to the hospital. This will often be a symptom.

Question 3

Chief Complaint

Answer 3

The reason, in the patient’s own words, for presenting to the hospital.

Question 4

Comorbidities

Answer 4

Preexisting diagnoses or conditions that are present on admission.

Question 5

Consultant

Answer 5

Healthcare provider who is asked to see the patient to provide expert opinion outside the expertise of the requester.

Question 6

Healthcare Provider

Answer 6

Person who provides care to a patient.

Question 7

Hybrid

Answer 7

A combination of formats producing similar results (i.e., paper and electronic records).

Question 8

Integral

Answer 8

Essential part of a disease process

Question 9

Physician

Answer 9

Licensed medical doctor.

Question 10

Principal Diagnosis

Answer 10

The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Question 11

Progress Notes

Answer 11

Daily recordings by healthcare providers of patient progress.