| Term | Definition |
|---|
| medical record | written report of the important information regarding a pt. including care and progress |
| catagories of MR | administrative, clinical, lab, diagnostic, therapeutic, hospital, and consent |
| pt. registration record (admin.) | demographic information, billing information |
| correspondence (admin.) | between individuals or facilities, contact with pt., |
| health history report (clinical) | collection of subjective data about pt.; determine pt. health status, to diagnose, and prscribe treatment. |
| diagnosis | scientific method of determining/identifying pt. condition |
| physical examination report (clinical) | an assessment of each part of the pt. body; to provide objective data about pt. and assist in dertmining pt. health status |
| progress note (clinical) | updating the MR with new information each time pt. is seen or calls; document pt. health status after each visit. |
| medication record (clinical) | detailed info on pt. medications |
| prescription/OTC medications record form (clinical) | records the pt. prescriptions and OTC meds; name, allergies, start date, med name, dosage, route, refills, stop date |
| medication administration record (clinical) | records medications admistered to pt. by medical office; name, allergies, name of med, dosage, route, injection site, date of admin, manufaturerer, sign. of administor |
| consultation report (clinical) | narrative report of a clinical opinion on pt. condition by phys. other than primary |
| home health care report (clinical) | provision of medical/non-medical care in pt. home; to minimize the effects of disease/disability by promoting, maintaining and restoring pt. health |
| laboratory report | analysis or examination of body specimens; assists in diagnosis and treatment |
| diagnostic procedure document (lab) | narrative description/interpretation of diagnostic procedure; ECG, holter monitor, sigmoidoscopy, colonoscopy, spirometry, radiology, and diagnostic imaging. |
| diagnostic procedure | procedure performed to assist in pt. diagnosis, management, treatment; ECG, holter monitor, sigmoidoscopy, colonoscopy, spirometry, radiology, and diagnostic imaging. |
| therapeutic service documents | assessments/treatments to restore pt. ability to function; PT, OT, ST |
| PT (theraputic) | to restore function and promote healing after illness or injury |
| OT (theraputic) | help pt. learn new skill to adapt to a phys, developmental, emotional, mental disability |
| ST (theraputic) | treatmen for the correction of speech impairment |
| Hopital documents | prepared by attending physician for care of pt. while at the hospital |
| attendign physician | doc responsible for care of pt. while at hospital |
| history and phycial report | document the pt. current complaints/condition/symptoms; must be done unless phy exam was performed 1 week before admission |
| inpatient | pt. admitted to the hospital for at least overnight |
| medical impressions | conclusions drawn from interpretation of data |
| operative report (hopital) | any pt. who undergoes surgery; describes surgery |
| discharge summary (hopital) | to provide for the continuation of care. brief summary of significant events during pt. hospitalization; done by attending phys.; pt. illness, course of treatment, response to treatment, pt. condition at time of discharge |
| pathology report (hopital) | macroscopic/microscopic description of tissue removed from pt. during surgery or diagnostic procedure; diagnosis |
| emergency dept. report (hopital) | record significant info obtained during ER visit; purpose is to provide follow-up care |
| consent documents | legal documents required to perform certain procedures or to release information in pt. MR |
| consent to treatment form | required for all surgical operations/non-routine therapeutic and diagnostic procedures; provide written evidence that pt. agress to procedure(s) on form |
| informed consent | pt. has received info on nature of pt. condition, nature/purpose of procedure, explaination of risks of procedure, alternative treaments, prognosis, risks of declining. |
| witnessing a signature | MA verified that pt. identity and wtch pt. sign form. |
| release of medical info form (consent) | pt. moving, change doc, for transfer of MR |
| PPRs | paper-based pt. record |
| EMR | electronic medical record |
| source-oriented format (PPR) | most common; organized by section based on dept (history/progress/lab/etc); in reverse chonological order |
| reverse chronological order | most recent document is place on top of MR |
| problem-oriented record/POR, POMR (PPR) | organized based on pt. health problems; pt. problems are defined/followed individually; est. database/compile problem list (placed at top of MR)/devise plan/follow problem w/ progress notes |
| problem | any pt. condition that requires observation, diagnosis management or pt. edu; not just phy but phsychological/social problems also |
| progress notes (POR, POMR) | SOAP: Subjective, Objective, Assessment, Plan |
| health history | collectioin of subject health data obtained from pt.; taken before phy. exam; ID data/CC/present illness (PI)/past history/family history/social history/review of systems (ROS) |
| identification data (health history) | demographic info |
| chief complaint, CC (health history) | pt. reason for seeking care; foundation for detailed info; use open-ended ?'s/limit to 1 or 2 symptoms/recored concisely and briefly/list duration of symptoms/NO diagnostic terms/NO diagnosising |
| present illnes, PI (health history) | expansion on CC; find out details of illness from pt. (homework) |
| past history (health history) | review of pt. past medical status; helps phy. offer optimal care; major illnesses/childhood illnesses/infections/accidents/etc. |
| family history (health history) | review of health status of pt. blood relatives |
| familial disease (health history) | disease that occurs in or affects blood relatives more freq. than chance |
| social history (health history) | pt. lifestyle; has impact on on pt. condition and course of treatment |
| review of symptoms, ROS (health history) | systematic review of each body system |
| charting | process of making wirtten entries about pt. in MR |
| charting guidelines | check pt. name and DOB/black ink/legible handwriting/accurately with clear and concise phrases/chart immediately after performing procedure/entries should be signed by MA making it/NEVER erase/ |
| symptom | any change in the body or its functioning that indicates the presence of disease |
| subjective symptom | one felt by the pt. but not observed |
| objective symptom | one that can be observed by another |
| nausea (GI) | sensation of discomfor in the stomach with a feeling that vomiting may occur |
| vomiting (GI) | the ejection of the stomach contents through the mouth (emesis) |
| cough (Resp) | involuntary and forceful exhalation of air followed by a deep inhilation; may be productive/non-productive |
| cyanosis (Resp) | a bluish discoloration of the skin due to a lack of oxygen |
| dyspnea (Resp) | labored or difficult breathing |
| epistaxis (Resp) | hemorrhaging from the nose (nosebleed) |
| chills (CNS) | feeling of coldness acoompanied by shivering; usually present w/ a fever |
| convulsions (CNS) | involuntary contractions of the muscles |
| fever, or pyrexia (CNS) | body temperature higher than usual |
| headache (CNS) | feeling of pain or aching in the head |
| malaise (CNS) | vague sens of body discomfort, weakness, and fatigue; often marking the onset of disease and cont. through course of illness |
| pain (CNS) | irritation of pain receptor, resulting in a feeling of distress or suffering; imp. indication that a part of the body is not working properly |
| pruritus (CNS) | severe itching |
| vertigo (CNS) | feeling of dissiness or lightheadedness |
| anorexia (GI) | loss of appetite and lack of interest in food |
| constipation (GI) | cond. in which the stool become hard/dry, resulting in difficult passage from the rectum; determined by consistency rather than frequency; |
| diarrhea (GI) | passage of an increased number of loose, watery stools; fecal material moves rapidly thorugh the intestinal tract resulting in decreased absorption of water, electrolytes and nurtients |
| flatulence (GI) | presence of excessive gas in the stomach/intestines |
| diaphoresis (integumentary) | excessive perspiration |
| flushing (integumentary) | read appearance to the skin; generally affects the face/neck; present w/ fever, freq. |
| jaundice (integumentary) | yelow appearance of skin, first evident in whites of the eyes |
| rash (integumentary) | eruption on the skin |
| bradycardia (Circulatory) | abnormally slow pulse rate |
| dehydration (Circulatory) | decrease in the amount of water in the body; pt. has flushed appearance, dry skin and decreased output of urine |
| edema (Circulatory) | retention of fluid in the same tissues, resulting in swelling; skin over the area is tight; not easily observed in the extremeties |
| tachycardia (Circulatory) | abnormally fast pulse rate |
| pyrexia (CNS) | fever; body temp. higher than usual |
Combine with other sets
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