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14 Cards in this Set

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