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Attending physician
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The physician responsible for the care of a hospitalized Pt
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terms list
Attending physician
The physician responsible for the care of a hospitalized Pt
Charting
The process of making written entries about a pt in the medical record
Consultation report
A narrative report of an opinion about a pts condition by a practitioner other than the attending physician
Diagnosis
The scientific method of determining and identifying a pt's condition
Diagnostic procedure
A procedure performed to assist in the diagnosis, management, or treatment of a Pt's condition
Discharge summary report
A brief summary of the significant events of a pt's hospitalization
Electronic Medical record (EMR)
A medical record that is stored on a computer
Familial
Occurring or affecting members of a family more frequently than would be expected by chance.
Health history report
A collection of subjective data about a Pt
Home health care
The provision of medical and non medical care in a pt's home or place of residence
Informed consent
Consent given by a pt for a medical procedure after being informed of the nature of his or her condition, the purpose of the procedure, an explanation of risks involved with the procedure, alternative treatments or procedures available,t he likely outcome of the procedure, and the risk involved with declining or delaying the procedure.
Inpatient
A pt who has been admitted to a hospital for at least one overnight stay
Medical impressions
Conclusions drawn by the physician from an interpretation of data. Other terms for impressions include provisional diagnosis and tentative diagnosis
Medical record
A written record of the important information regarding a pt, including the care of that individual and the progress of the pt's condition.
Medical record format
The way a medical record is organized. The two main types of medical record formats are the source-oriented record and the problem-oriented record.
Objective symptom
A symptom that can be observed by an examiner
Paper-based pt record (PPR)
A medical record in paper form,
Patient
an individual receiving medical care
Physical examination
An assessment of each part of the pt's body to obtain objective data about the pt that assists in determining the pt's state of health
Physical examination report
A report of the objective findings form the physician;s assessment of each body system
Problem
Any condition that requires further observation diagnosis, management, or pt education
Prognosis
The probable course and outcome of a disease and the prospects for a pt's recovery
Reverse chronological order
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 or file.
SOAP format
A method of organization for recording progress notes. The SOAP format includes the following categories: subjective data, assessment, and plan
subjective symptom
A symptom hat is felt by the pt, but is not observable by an examiner
Symptom
Any change in the body or its functioning that indicates the presence of disease
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