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14 Cards in this Set
- Front
- Back
to show a mutual relationship
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correlation
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the determination of the nature/cause of a disease
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diagnosis
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to see or understand a difference between two things
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discernible
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being an indispensable part of a whole
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integral
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a complete set of information put down in writing to authenticate evidence of facts and events
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medical record
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a permanent legal document formally stating the results of an examination
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medical report
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perceptible to the observer/external senses (ie Dr.s conclusions)
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objective
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an inference from what has been seen or heard
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observation
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competency as a result of training & experience
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proficiency
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the forecast of the outcome of a disease/injury
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prognosis
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records of patient visits, phone calls, progress & treatment that are inserted into the pts. chart
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progress notes
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any objective evidence of disease discoverable by a Dr. on examination of a patient
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sign
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findings percepible only by the affected person
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subjective
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any perceptible change in the body or its functions (indicating disease or illness)
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symptom
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