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20 Cards in this Set
- Front
- Back
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Home Health Care
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Provision of medical and nonmedical care in a person's place of residence
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Electronic medical record
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Medical record that is stored in a computer
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SOAP
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Method for recording progress notes; Subjective Objective Assessment Plan
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Inpatient
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A pt. who has been admitted to the hospital for at least 1 nights stay
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Diagnostic procedure
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A procedure(test) preformed to assist in diagnosis, management, treatment of patients condition
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charting
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written entries about a pt in the medical record
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medical record
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detailed information regaurding pt's medications, including OTC (over the counter)
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Objective Symptom
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A symptom observed by the examiner
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subjective symptom
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A symptom felt by the pt. Examiner cannot see or feel it
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Informed Consent
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Agreement for a procedure based on understanding information
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Reverse Chronological Order
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Documents filed with the most recent document on top, oldest on the bottem
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Consultation report
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a narrative report of an opinion regaurding pt's condition by practitioner
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attending physician
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the dr. responsible for the care of a hospitalized pt.
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HIPAA
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Health Insurance Portability and Accountabilty Act
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Patient registration record
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form for a patients demoraphic and billing information
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progress notes
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recording pt's medical record with new information regaurding: office visits, telephone calls, Rx's, lab tests, etc...... Any info regaurding pt
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CC
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cheif complaint
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d/c
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discontinue
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N/C
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No complaints
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N&V
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Nausea and Vommiting
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