Definitions

Question 1

Attending physician

Answer 1

The physician responsible for the care of a hospitalized patient.

Question 2

Chief complain

Answer 2

A statement of the most important symptoms for which a patient is seeking care

Question 3

Consulting report

Answer 3

A narrative report of an opinion about a patients condition by a practitioner other than the attending physician.

Question 4

Diagnosis

Answer 4

The scientific method of determining and identifying a patients condition.

Question 5

Diagnostic procedure

Answer 5

A procedure performed to assist in the diagnosis, management, or treatment of a patient’s condition

Question 6

Digital image

Answer 6

A picture that is stored electronically to allow viewing on a computer.

Question 7

Discharge summary report

Answer 7

A brief summary of the significant events of a patients hospitalization.

Question 8

Documenting

Answer 8

The process of making written or electronic entries about a patient in the medical record.

Question 9

Electronic medical record

Answer 9

A patients health record that is stored on a computer.

Question 10

Familial

Answer 10

Occurring in or affecting members of a family more frequently than would be expected by chance.

Question 11

Flow sheet

Answer 11

A paper document or electronic screen that allows similar data to be recorded and viewed chronologically

Question 12

A collection of subjective data about the patient

Answer 12

Health history

Question 13

The provision of medical and nonmedical care in a patients home or place of residence

Answer 13

Home health care

Question 14

A patient who has been admitted to a hospital for at least one overnight stay

Answer 14

Inpatient

Question 15

A written record of important information regarding a patient, including the care of that individual and the progress of the patients condition.

Answer 15

Medical record

Question 16

The way a medical record is organized. The two main types of medical record formats are source orientated and problem orientated

Answer 16

Medical record format

Question 17

A symptom that can be observed by an examiner

Answer 17

Objective symptom

Question 18

A medical record in paper form

Answer 18

Paper-based patient record

Question 19

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

Answer 19

Physical examination

Question 20

Any condition that requires further observation, diagnosis, management, or patient education

Answer 20

Problem

Question 21

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

Answer 21

Reverse chronological order

Question 22

A method of organization for recording progress notes. Including: subjective data, objective data, assessment, and plan

Answer 22

SOAP

Question 23

A symptom that is felt by the patient but it is not observable by an examiner

Answer 23

Subjective symptom

Question 24

Any change I. The body it it’s function that includes the presence of disease

Answer 24

Symptom