MOPS

CORRELATION

To show a mutual relationship
DIAGNOSIS

The determination of the nature\ cause of a disease.
DISCERNIBLE

To see or understand a difference between two things.
INTEGRAL

Being an indispensable part of a whole.
MEDICAL RECORD

A complete set of information put down in writing to authenticate evidence of facts and events.
MEDICAL REPORT

A permanent legal document formally stating the results of an examination.
OBJECTIVE (info)

Preceptible to the observer\external senses (i.e. Dr's conclusions).
OBSERVATION

An inference from what has been seen or heard.
PROFICIENCY

Competency as a result of training & experience.
PROGNOSIS

The forecast of the outcome of a disease\injury.
PROGRESS NOTES

Records of patient visits, phone calls, progress & treatment that are inserted into the pts. chart.
SIGN

Any objective evidence of disease discoverable by a Dr. on examination of a patient.
SUBJECTIVE

Findings perceptible only by the affected person.
SYMPTOM

Any perceptible change in the body or its functions (Indicating disease or illness).

Author

shaketarenae

40916

Card Set

MOPS

Description

The Patient Record/The Medical Record

Updated

2010-10-09T23:09:05Z

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