Definitions Flashcards
Attending physician
The physician responsible for the care of a hospitalized patient.
Chief complain
A statement of the most important symptoms for which a patient is seeking care
Consulting report
A narrative report of an opinion about a patients condition by a practitioner other than the attending physician.
Diagnosis
The scientific method of determining and identifying a patients condition.
Diagnostic procedure
A procedure performed to assist in the diagnosis, management, or treatment of a patient’s condition
Digital image
A picture that is stored electronically to allow viewing on a computer.
Discharge summary report
A brief summary of the significant events of a patients hospitalization.
Documenting
The process of making written or electronic entries about a patient in the medical record.
Electronic medical record
A patients health record that is stored on a computer.
Familial
Occurring in or affecting members of a family more frequently than would be expected by chance.
Flow sheet
A paper document or electronic screen that allows similar data to be recorded and viewed chronologically
A collection of subjective data about the patient
Health history
The provision of medical and nonmedical care in a patients home or place of residence
Home health care
A patient who has been admitted to a hospital for at least one overnight stay
Inpatient
A written record of important information regarding a patient, including the care of that individual and the progress of the patients condition.
Medical record
The way a medical record is organized. The two main types of medical record formats are source orientated and problem orientated
Medical record format
A symptom that can be observed by an examiner
Objective symptom
A medical record in paper form
Paper-based patient record
An assessment of each part of the patients body to obtain objective data about the patient that assists the physician in determining the patients state of health
Physical examination
Any condition that requires further observation, diagnosis, management, or patient education
Problem
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 file
Reverse chronological order
A method of organization for recording progress notes. Including: subjective data, objective data, assessment, and plan
SOAP
A symptom that is felt by the patient but it is not observable by an examiner
Subjective symptom
Any change I. The body it it’s function that includes the presence of disease
Symptom
