test 1: ch1 other terms Flashcards
details patients history, results of physicians examination, initial diagnoses, and physicians plan of treatment
history and physical
complete list of care, medications, tests, and treatments physician orders for the patient
physicians orders
record of patients care throughout the day; includes vital signs, treatment specifics, patients response to treatment, and patients condition
nurse’s notes
physicians daily record of patients condition, results of physicians examinations, summary of test results, updated assessment and diagnoses, and further plans for patients care
physicians progress notes
reports given by specialists whom physician has asked to evaluate patient
consultation reports
reports from various treatments and therapies patient has received, such as rehabilitation, social services, or respiratory therapy
ancillary reports
results of diagnostic tests performed on patient, principally from clinical lab and medical imaging
diagnostic reports
document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure
informed consent
report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical procedure itself, and how patient tolerated procedure
operative report
relates details regarding substances given to patient, patients response to anesthesia, and vital signs during surgery
anesthesiologists report
report given by pathologist who study tissue removed from patient
pathologist’s report
comprehensive outline of patients entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient’s response, final diagnosis, and follow-up plans
discharge summary
provide services to diagnose and treat diseases for a short period of time; in addition, they usually provide emergency and obstetrical care
acute care or general hospitals
provide care for very specific types of diseases
specialty care hospitals
provide long-term care for patients needing extra time to recover from illness or injury before returning home or for persons who can no longer care for themselves
nursing homes or long-term care facilities
provide services not requiring overnight hospitalization; services range from simple surgeries to diagnostic testing or therapy
ambulatory care centers, surgical centers, or outpatient clinics
provide diagnostic and treatment services in a private office setting
physician’s offices
provides a wide range of services by a group of primary-care physicians, specialists, and other healthcare professionals in a prepaid system
health maintenance organization (HMO)
provides nursing, therapy, personal care, or housekeeping services in patients own home
home health care
provide intensive physical and occupational therapy; includes inpatient and outpatient treatment
rehabilitation centers
provide supportive treatment to terminally ill patients and their families
hospices
study of the origin, characteristics, and effects of drugs
pharmacology
describes the chemical formula or molecular structure of a particular drug
chemical name
recognized and accepted as the official name for a certain drug
generic or nonproprietary
