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28 terms

ch 23

definitions
STUDY
PLAY
chief complaint
specific symptom or problem for which the patient is seeing the physician today.
review of systems
inquires about the system directly related to the problems identified in the history of the present illness.
source-oriented medical record
a type of patient chart record keeping that incldues seperate sections for different sources of patient information.
present illness
what the patient is feeling specifically
past medical history
includes all health problems, major illnesses, and surgeries that the patient has had.
family history
provides clues to the patient's present condition by asking open-ended questions about medical problems of siblings, parents, and grandparents. This will alert the physician to any hereditary and familial diseases and disorders.
social history
includes their marital status, sexual habits, occupation, hobbies, and use of alcohol, tobacco, and recreational drugs or other chemical substances.
subjective
symptom that is felt by the patient but not observed by others.
objective
a patient sign that is visible, palpable, or measurable by an observer.
assessment
...
plan
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patient demographic data form
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release of information
A statement that permits the provider to give the carrier information needed to help process the claim.
medical history form
commomly used to gather information from the patient before the visit
financial information form
...
documentation
providing factual support through written information.
communication
the interchange of thoughts, opinions, or information by speech, writing, or signs.
allergies
acquired hypersensitivity to a substance.
immunizations
protection of individuals or groups from a specific diseases by vaccination or the injection of immune globulins
diagnosis
determination of disease or condition.
history
the written and other recorded events of people
charting
required for each medication, treatment/procedure, or medical assistant action; it accounts of the patient's condition and activities must be charted in a clear and meaningful way.
medications
drugs that are administered to a patient who is sick or in pain
culture
microorganisms cultivated in a nutrient medium.
emergency
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interacting
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administrative
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computerized
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