MAI140 Ch 1
The physician responsible for the care of a hospitalized patient.
The process of making written enteries about a patient in the medical record.
A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician.
The scientific method of determining and identifying a patient's condition.
A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition.
A medical record that is stored on a computer.
Electronic medical record
A brief summary of the significant events of a patient's hospitalization.
Discharge summary report
Occurring or affecting members of a family more frequently than would be expected by chance.
A collection of subjective data about a patient.
Health history report
The consent given by a patient for medical treatment after being informed of the procedure.
A patient who has been admitted to the hospital for at least one overnight stay.
The conclusions reached by the physician from an interpretation of data.
A written record of the important information regarding a patient.
A symptom that can be observed by an examiner.
An individual receiving medical care.
A report of the objective findings from the physician's assessment of each body system.
Physical examination report
Any conditin that requires further observation, dianosis, management, or patient education.
The probable course and outcome of a disease and the prospect for recovery.
A symptom felt by the patient but not observed by the examiner.
Any change in the body or its functioning indicative that a disease is present.
MAI140 Ch 1
The Medical Record: Key Terms