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Study sets matching "medical record"

27 terms
The Medical Record
HPI (History of Present Illness)
Location
Severity
Timing
Where you would document the history of the patient's chief c…
The location of the chief complaint (i.e. left chest, lower a…
The severity of the pain/chief complaint (i.e. mild, moderate…
The frequency of the chief complaint (i.e. constant, intermit…
HPI (History of Present Illness)
Where you would document the history of the patient's chief c…
Location
The location of the chief complaint (i.e. left chest, lower a…
30 terms
Medical Record
Registration Form
HIPAA Consent Form
Release of Information
Release to Treat Form; Also Known As T…
Includes: Patient demographics, insurance information, emerge…
A voluntary agreement that a patient gives to allow a medical…
A signed consent form for treatment of care or authorized pro…
The portion of HIPAA that allows the provider to use and shar…
Registration Form
Includes: Patient demographics, insurance information, emerge…
HIPAA Consent Form
A voluntary agreement that a patient gives to allow a medical…
12 terms
The Medical Record
History and Physical
Physician's Orders
Nurse's Notes
Physician's Progress Notes
Written or dictated by admitting physician; details patient's…
Complete list of care, medications, tests, and treatments phy…
Record of patient's care throughout the day; includes vital s…
Physicians daily record of patient's condition, results of ph…
History and Physical
Written or dictated by admitting physician; details patient's…
Physician's Orders
Complete list of care, medications, tests, and treatments phy…
12 terms
The Medical Record
1. History and Physical
2. Physician's Orders
3. Nurse's Notes
4. Physician's Progress Notes
Written or dictated by admitting physician; details patient's…
Complete list of care, medications, tests, and treatments phy…
Record of patient's care throughout the day; includes vital s…
Physician's daily record of patient's condition, results of p…
1. History and Physical
Written or dictated by admitting physician; details patient's…
2. Physician's Orders
Complete list of care, medications, tests, and treatments phy…
161 terms
The Medical Record
H&P
CC
HPI (PI)
Sx
History and Physical
Chief Complaint
History of Present Illnesses
Symptoms
H&P
History and Physical
CC
Chief Complaint
18 terms
Medical record
PMH or PH
Info regarding
FH
SH
Past medical history
Childhood disease
Family history ... -sibling ... -parents... -death... -disease
Social history... -personal habit, ex cerise, sleep, diet, tobac…
PMH or PH
Past medical history
Info regarding
Childhood disease
34 terms
The Medical Record
H&P
Hx
CC
c/o
history and physical
history
chief complaint
complains of
H&P
history and physical
Hx
history
20 terms
Medical Record
history and physical
acute care hospital
consultation report
home healthcare
written by admitting physician, includes initial diagnosis
provides services for a short period of time
written by specialist who has seen patient
provides services in patient's own home
history and physical
written by admitting physician, includes initial diagnosis
acute care hospital
provides services for a short period of time
23 terms
The Medical Record
Attending physician
Consultation report
Diagnosis
Diagnostic procedure
The physician responsible for the care of a hospitalized pati…
A narrative report of an opinion about a patient's condition…
The scientific method of determining and identifying a patien…
A procedure performed to assist in the diagnosis, management,…
Attending physician
The physician responsible for the care of a hospitalized pati…
Consultation report
A narrative report of an opinion about a patient's condition…
12 terms
Medical Record
History and Physical
Physician's orders
Nurse's notes
Physicians's progress notes
written or dictated by admitting physician; details patients…
complete list of care, medications, tests, and treatments phy…
record of patient's care throughout the day; includes vital s…
physician's daily record of patients condition, results of ph…
History and Physical
written or dictated by admitting physician; details patients…
Physician's orders
complete list of care, medications, tests, and treatments phy…
12 terms
Medical Record
History and Physical
Physicians Orders
Nurses Notes
Physicians Progress Notes
details patients history
Complete list of care, medications, tests, and treatments phy…
Vital signs, treatment specifics, patient's response and cond…
Daily record of patient's condition, results of physician's e…
History and Physical
details patients history
Physicians Orders
Complete list of care, medications, tests, and treatments phy…
12 terms
Medical Record
History and Physical
Physician's Orders
Nurses Notes
Physician's Progress Notes
Written or dictated by the admitting physician; details the p…
Complete list of care, medications, tests and treatments the…
Record of the pt.'s care throughout the day: Includes vital s…
Physician's daily record of the pt.'s condition, results of t…
History and Physical
Written or dictated by the admitting physician; details the p…
Physician's Orders
Complete list of care, medications, tests and treatments the…
15 terms
Medical Record
abbreviations
medical record
electronic medical record
History and Physicals
commonly used as a way of saving time but some can be confusi…
chart documents that detail the patients hospital stay thus r…
software system that is used to enter patient information int…
written or dictated by admitting physician; details patient's…
abbreviations
commonly used as a way of saving time but some can be confusi…
medical record
chart documents that detail the patients hospital stay thus r…
17 terms
The Medical Record
medical record
Problem-Oriented Medical Record (POMR)
SOAP
timeliness of documentation
All of the written documentation relating to the patient. It…
Medical charting that includes the chronological record of ea…
Subjective, objective, assessment plan. Subjective statements…
All entries should be made as they occur or as soon as possib…
medical record
All of the written documentation relating to the patient. It…
Problem-Oriented Medical Record (POMR)
Medical charting that includes the chronological record of ea…
11 terms
Medical Record
Physician's Orders
Nurse's Notes
Physician's Progress Notes
Consultation Reports
complete list of care, medications, tests, and treatments phy…
record of patient's care throughout the day; includes vital s…
Physician's daily record of patient's condition, results of p…
reports given by specialists whom physician asked to evaluate…
Physician's Orders
complete list of care, medications, tests, and treatments phy…
Nurse's Notes
record of patient's care throughout the day; includes vital s…
12 terms
Medical record
History and physical
Physicians orders
Nurses notes
Physicians progress notes
Written or dictated, details patients history, result of phys…
Complete list of care, medications, tests, and treatments phy…
Record of patients care throughout the day; includes vital si…
Physicians daily record of patients condition, result of phys…
History and physical
Written or dictated, details patients history, result of phys…
Physicians orders
Complete list of care, medications, tests, and treatments phy…
14 terms
MEDICAL RECORD
Medical Record or Chart
Electronic Medical Record (EMR)
History and Physical
Physician's Orders
documents the details of a patient's stay in the hospital
software program that allows you to enter the patients inform…
written or dictated by admitting physicians; details patient'…
complete list of care, medication, tests, and treatments whic…
Medical Record or Chart
documents the details of a patient's stay in the hospital
Electronic Medical Record (EMR)
software program that allows you to enter the patients inform…
12 terms
Medical Record
DISCHARGE SUMMARY
PATHOLOGIST'S REPORT
ANESTHESIOLOGIST'S REPORT
OPERATIVE REPORT
Comprehensive outline of patient's entire hospital stay; incl…
Report given by pathologist who studies tissue removed from p…
Relates details regarding substances given to patient, patien…
Report from surgeon detailing an operation; includes pre and…
DISCHARGE SUMMARY
Comprehensive outline of patient's entire hospital stay; incl…
PATHOLOGIST'S REPORT
Report given by pathologist who studies tissue removed from p…
12 terms
Medical Record
History and physical
Physicans orders
Nurses notes
Physicians progress notes
Written or dictated by admitting physicians; details patient'…
Complete list of care, medications, test, and treatment physi…
Record of patient's care throughout the day; includes vital s…
Daily record of patient's condition, results of physicians ex…
History and physical
Written or dictated by admitting physicians; details patient'…
Physicans orders
Complete list of care, medications, test, and treatment physi…
12 terms
Medical record
History and physical
Physicians order
Nurses Note
Physicians Progress Notes
Written or dictated by the admitting physician; details patie…
Complete list of the care, medications, tests, and treatments…
Record of the patients care throughout the day; includes vita…
Physicians daily record of the patients condition, results of…
History and physical
Written or dictated by the admitting physician; details patie…
Physicians order
Complete list of the care, medications, tests, and treatments…
12 terms
Medical Record
History and Physical
Physician's Orders
Nurse's Notes
Physician's Progress Notes
written or dictated by admitting physician; details patient's…
Complete list of care, medications, tests and treatments phys…
Record of patient's care throughout the day; includes vital s…
Physician's daily record of patient's condition, results of p…
History and Physical
written or dictated by admitting physician; details patient's…
Physician's Orders
Complete list of care, medications, tests and treatments phys…
23 terms
Medical Record
Medical Record
Electronic Medical Record (EMR)
History and Physical
Physician's Orders
Documents details of patient's hospital stay; each health car…
A software program used to enter patient information into a c…
Written or dictated by admitting physician; details of patien…
Complete list of care, medications, tests, and treatments phy…
Medical Record
Documents details of patient's hospital stay; each health car…
Electronic Medical Record (EMR)
A software program used to enter patient information into a c…
12 terms
Medical Record
History and Physical
Physicians Orders
Nurses Notes
Physician Progress notes
Written by admitting physician; details patients history, res…
Complete list of care, meds, tests, and treatments physicians…
record of patients care throughout the day; include vital sig…
physicians daily record of patients condition, results of phy…
History and Physical
Written by admitting physician; details patients history, res…
Physicians Orders
Complete list of care, meds, tests, and treatments physicians…
13 terms
Medical Record
The Medical Record
History & Physical
Physician's Orders
Nurse's Notes
legal docs maintained in file room for quick and complete ref…
written/dictated by admitting physician; contains patient's m…
complete list of all care, medications, tests, and treatments…
record of patient's care throughout the day; includes vital s…
The Medical Record
legal docs maintained in file room for quick and complete ref…
History & Physical
written/dictated by admitting physician; contains patient's m…
20 terms
Medical Record
history and physical
acute care hospital
consultation report
home healthcare
written by admitting physician, includes initial diagnosis
provides services for a short period of time
written by specialist who has seen patient
provides services in patient's own home
history and physical
written by admitting physician, includes initial diagnosis
acute care hospital
provides services for a short period of time
12 terms
Medical Record
History and Physical
Physician's Orders
Nurse's Notes
Physician's progress notes
Written or dictated by admitting physician; details patient h…
Complete list of care, medications, tests, and treatments phy…
Record of patients care throughout the day; includes vital si…
Physicians daily record of patients condition, results of phy…
History and Physical
Written or dictated by admitting physician; details patient h…
Physician's Orders
Complete list of care, medications, tests, and treatments phy…
The Medical Record
History and Physical
Consultation report
Ancillary report
Nurse's notes
Written by admitting physician; includes initial diagnoses
Written by specialist who has seen patient
reports results from various treatments and therapies patient…
record of patients care throughout the day
History and Physical
Written by admitting physician; includes initial diagnoses
Consultation report
Written by specialist who has seen patient
12 terms
The Medical Record
History and Physical
Physicians Orders
Nurse's Notes
Physician's Progress Notes
Written or dictated by admitting physician; details patient's…
Complete list of care, medications, tests, and treatments phy…
Record of patient's care throughout the day; includes vital s…
Physician's daily record of patient's condition, results of p…
History and Physical
Written or dictated by admitting physician; details patient's…
Physicians Orders
Complete list of care, medications, tests, and treatments phy…
12 terms
The Medical Record
History and Physical
Physician's Orders
Nurse's notes
Physician's Progress Notes
written or dictated by admitting physician; details patient's…
complete list of care, medications, tests, and treatments phy…
record of patient's care throughout the day; includes vital s…
Physician's daily record of patient's condition, results of p…
History and Physical
written or dictated by admitting physician; details patient's…
Physician's Orders
complete list of care, medications, tests, and treatments phy…
12 terms
The Medical Record
History and Physical
Physician's Orders
Consultation Reports
Nurse's Notes
Written or dictated by admitting physician; details patient's…
Complete list of care, medications, tests, and treatments phy…
Reports given by specialists whom physician has asked to eval…
Record of patient's care throughout the day;including vital s…
History and Physical
Written or dictated by admitting physician; details patient's…
Physician's Orders
Complete list of care, medications, tests, and treatments phy…
12 terms
The Medical Record
history & physical
physician's orders
nurse's notes
physician's progress notes
written by the admitting physician
complete list of care, medications, tests,and treatments phys…
record of a patient's care throughout the day
contains updated assessment, diagnoses, and further plans for…
history & physical
written by the admitting physician
physician's orders
complete list of care, medications, tests,and treatments phys…
27 terms
The Medical Record
H&P
Hx
Subjective Information
CC
-History and Physical... -Documentation of patient history and p…
-History... -Record of subjective information regarding the pati…
Information obtained from the patient including his or her pe…
Chief Complaint
H&P
-History and Physical... -Documentation of patient history and p…
Hx
-History... -Record of subjective information regarding the pati…
27 terms
2. The Medical Record
HPI (History of Present Illness)
Location
Severity
Timing
Where you would document the history of the patient's chief c…
The location of the chief complaint (i.e. left chest, lower a…
The severity of the pain/chief complaint (i.e. mild, moderate…
The frequency of the chief complaint (i.e. constant, intermit…
HPI (History of Present Illness)
Where you would document the history of the patient's chief c…
Location
The location of the chief complaint (i.e. left chest, lower a…
24 terms
Medical record
Purging
Ownership of physical medical record
___owns the information of the medical…
_____is the most efficient record
The process of moving active files to inactive status
Physician
Patient
Electronic medical record
Purging
The process of moving active files to inactive status
Ownership of physical medical record
Physician
42 terms
medical record
medical record
medical record
animal history
stamp/write
a compilation of pertinent facts about the animal patients li…
serves as a basis for planning animals care, includes past/pr…
provided by owner, tech and doctor observations and lab resul…
identifying animals info on each page
medical record
a compilation of pertinent facts about the animal patients li…
medical record
serves as a basis for planning animals care, includes past/pr…
13 terms
The Medical Record
proper patient identification informat…
history and physical (H&P)
physican orders
nurses notes
patient's name, age, gender, physician, admission date, and i…
(1) written or dictated by admitting physician; details patie…
(2) complete list of all care, medications, tests, treatments…
(3) record of patient's care throughout the day which include…
proper patient identification informat…
patient's name, age, gender, physician, admission date, and i…
history and physical (H&P)
(1) written or dictated by admitting physician; details patie…
55 terms
The Medical Record
H & P
History and Physical
Hx
History
History and Physical
documentation of patient history and physical examination fin…
History
record of subjective information regarding the patient's pers…
H & P
History and Physical
History and Physical
documentation of patient history and physical examination fin…
12 terms
Medical Record
History & Physical
Physician's Orders
Nurse's Notes
Physicians Progress Notes
Written by the admitting physician, patients history, results…
List of care, medications, tests, and treatment for patient.
Record of daily patient care ( vital signs, treatments, patie…
Daily record of patients condition, results of exams, summary…
History & Physical
Written by the admitting physician, patients history, results…
Physician's Orders
List of care, medications, tests, and treatment for patient.
The Medical Record
History and Physical
Consultation Report
Ancillary Report
Nurse's Notes
Written by admitting physician; includes initial diagnoses.
Written by specialist who has seen patient.
Reports results from various treatments and therapies patient…
Record of patient's care throughout the day.
History and Physical
Written by admitting physician; includes initial diagnoses.
Consultation Report
Written by specialist who has seen patient.
12 terms
The Medical Record
History and Physical
Physician's Orders
Nurse's Notes
Physician's Progress Notes
Written or dictated by admitting physician:... details Patient's…
Complete list of care, medications, tests and treatments phys…
Record of patient's care throughout the day:... includes vital s…
Physician's daily record of:... patient's condition... results of p…
History and Physical
Written or dictated by admitting physician:... details Patient's…
Physician's Orders
Complete list of care, medications, tests and treatments phys…
14 terms
The Medical Record
Medical Record
Electronic Medical Record (EMR)
History and Physical
Physician's Orders
Chart or documents that have the details of the patient's hos…
Software program that is used to enter patient information in…
Details patient's history, results of examinations, initial d…
Complete list of care, medications, tests and treatments.
Medical Record
Chart or documents that have the details of the patient's hos…
Electronic Medical Record (EMR)
Software program that is used to enter patient information in…
31 terms
Medical Record
aa (w/line above)
Ab
ac
ad lib
of each
abortion
before meals
as desired
aa (w/line above)
of each
Ab
abortion
12 terms
Medical Record
History and Physical
Physician's Orders
Nurse's Notes
Physician's Progress Notes
Written or dictated by admitting physician; details patient's…
Complete list of care, medications, tests and treatments phys…
Record of patient's care throughout the day; includes vital s…
Physician's daily record of patient's condition, results of p…
History and Physical
Written or dictated by admitting physician; details patient's…
Physician's Orders
Complete list of care, medications, tests and treatments phys…
25 terms
Medical record
Attending physician
Charting
Consultation report
Diagnosis
Physician responsible for the care of a hospitalized patient
Process of documenting info about a patient in the medical re…
Narrative report of an opinion about a patient's condition by…
Scientific method of determining and identifying a patient's…
Attending physician
Physician responsible for the care of a hospitalized patient
Charting
Process of documenting info about a patient in the medical re…
67 terms
Chapter 36: The Medical Record
Attending Physician
Charting
Consultation Report
Diagnosis
The physician responsible for the care of a hospitalized pati…
The process of of making written entries about a patient in t…
a narrative report of an opinion about a patient's condition…
The scientific method of determining and identifying a patien…
Attending Physician
The physician responsible for the care of a hospitalized pati…
Charting
The process of of making written entries about a patient in t…
12 terms
Medical Record
History and Physical
Physician's Orders
Nurse's Notes
Physician's Progress Notes
written or dictated by admitting physicians; details patient'…
Complete list of care, medications, tests, and treatments phy…
record of patient's care throughout the day; includes vital s…
Physician's daily record of patient's, results of physician's…
History and Physical
written or dictated by admitting physicians; details patient'…
Physician's Orders
Complete list of care, medications, tests, and treatments phy…
97 terms
Medical Terminology - Medical Record
H&P
Hx
CC
c/o
history and physical
History
Chief Complaint
complains
H&P
history and physical
Hx
History
12 terms
Medical Record
History and physical
Physician's orders
Physician's progress notes
Consultation reports
Written by admitting physician
List of physician orders for patients
physicians daily record of patients condition
reports given by a specialist
History and physical
Written by admitting physician
Physician's orders
List of physician orders for patients
17 terms
Medical Record
do not require a sign consent form.
behind an operative report from 2009
copies only
SOAP
Lawful mandatory reporting situations or subpoenas
Using reverse chronologic order filing, a surgical report fro…
When sending the medical record to another health care provid…
One of the most common methods of medical record documentatio…
do not require a sign consent form.
Lawful mandatory reporting situations or subpoenas
behind an operative report from 2009
Using reverse chronologic order filing, a surgical report fro…
12 terms
Medical record
History & physical
Physician's orders
Nurse's notes
Physician's progress notes
Written or dictated by admitting physician
List of care, medications, tests, and treatments physician or…
Record of patient's care throughout the day
Physician daily record of patients condition, results of phys…
History & physical
Written or dictated by admitting physician
Physician's orders
List of care, medications, tests, and treatments physician or…
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