The Medical Record

Front 1

Medical Record

Back 1

A written record of the important information regarding a patient.

Hint 1

Used as a basis for decisions and helps form the care and treatment of the patient.

Front 2

Patient Registration Record

Back 2

Consist of demographic and billing information, must be completed by all new patients.

Hint 2

PRR

Front 3

Correspondence

Back 3

Term for any patient specific information received from or sent by a doctor or Health Organization.

Front 4

7 Components of The Health History

Back 4

Identifying data, Chief complaint, present illness, past history, review of systems, family history, personal/social history.

Hint 4

ID,CC,PI,PH,ROS,FH,P/SH

Front 5

Health History Report

Back 5

A collection of subjective data about the patient, either pre-printed forum filled out by the patient or, a checkup from the doctor.

Hint 5

HRR

Front 6

Physical Examination Report

Back 6

Is a summary of The Physicians findings from the assessment of each part of the patient's body and includes the following: General appearance, Eyes, Ears, Nose, mouth and Pharynx, arms and hands, chest and lungs, Hart, breast, abdomen, genitals and rectum, legs and feet.

Hint 6

Check-Ups

Front 7

Progress Notes

Back 7

This involves updating the medical record with new information each time the patient visits or telephones the medical office.

Hint 7

Updating of the Medical Record

Front 8

Medication Record

Back 8

Consists of detailed information related to a patient's medications. Includes prescription medications, over the counter medications and any medications administered at the medical office.

Front 9

Consultation Report

Back 9

Is a narrative report of a clinical opinion about a patient's condition by a practitioner other than the primary physician.

Front 10

Home Health Care Report

Back 10

Is the provision of medical and non-medical Care in a patient's home or place of residence.

Front 11

Hematology Report

Back 11

Laboratory analysis that deals with the examination of the patient's blood. Includes areas such as blood cell counts, cellular morphology, clotting ability of the blood and identification of cell types.

Hint 11

Suffix for Blood

Front 12

Clinical Chemistry Report

Back 12

Laboratory analysis that involves detecting the presence of chemical substances for determining the amount of substances in bodily fluids /excretia and tissues. Largest area is blood.

Hint 12

CCR

Front 13

Serology Report

Back 13

Laboratory analysis that studies antigen and antibody reactions to assess the presence of a substance or to determine the presence of a disease.

Front 14

Urinalysis Report

Back 14

Laboratory analysis of the patient's urine. Includes physical chemical and microscopic analysis.

Front 15

Microbiology Report

Back 15

Laboratory analysis that deals with the identification of pathogens and specimens taken from the body.

Hint 15

Blood / semen / vaginal secretions / saliva

Front 16

Parasitology Report

Back 16

Laboratory analysis that deals with the detection of disease producing human parasites or eggs in specimens taken from the body.

Front 17

Cytology Report

Back 17

Laboratory analysis that deals with the detection of abnormal cells.

Hint 17

Abnormal Cell Detection

Front 18

Histology Report

Back 18

Laboratory analysis that deals with the detection of diseased tissue.

Front 19

Electrocardiogram Report

Back 19

Is a narrative description of a cardiologist's interpretation of an ECG. Graphics are usually included with the results.

Front 20

Holter Monitor Report

Back 20

Is a narrative description of the interpretation of an ambulatory electrocardiogram, including the evaluators Impressions. Graphics usually included with the results.

Front 21

Sigmoidoscopy Report

Back 21

Is a narrative description of the interpretation of the colon.

Hint 21

Anus, Colon

Front 22

Colonoscopy Report

Back 22

The narrative report of the anal cavity.

Front 23

Spiromerty Report

Back 23

Is a narrative description of the interpretation of pulmonary function tests.

Front 24

Radiology Report

Back 24

Is a narrative description of a diagnostic or therapeutic Radiologic procedure

Front 25

Diagnostic Imaging Report

Back 25

Includes a detailed interpretation of the diagnostic image, along with the practitioners impressions.

Hint 25

DIR

Front 26

History & Physical Reports

Back 26

Is a report of the patient's history and physical examination along with the Physicians Medical impressions.

Front 27

Operative Report

Back 27

Report describes the surgical procedure and must be completed and signed by the surgeon who performed the operation.

Front 28

Discharge Summary Report

Back 28

A brief summary of the significant events of the patients hospitalization. Completed by attending physician.

Front 29

PHI

Back 29

Patient History Information

Front 30

Pathology Report

Back 30

Consist of a microscopic and macroscopic description of the tissue removed from the patient during surgery for a diagnostic procedure.

Front 31

Emergency Room Report

Back 31

Is the record of the significant information obtained during an emergency room visit.

Front 32

Consent To Treatment Form

Back 32

Is required for all surgical operations and non routine Diagnostic and therapeutic procedures performed in the medical office.

Front 33

Release of Medical Information Form

Back 33

If patient is leaving State and needs to transfer his or her PHI, needs to sign a _________ form

Front 34

Informed Consent

Back 34

Means that the patient has received the following information before giving consent, the nature of the patient's condition, the nature and purpose of the recommended procedure, risk factors involved, possible other treatments, likely outcome, risks of declining / delaying the procedure.

Front 35

Diagnostic Procedure

Back 35

Procedure performed to assist in the diagnosis, management or treatment of a patient's condition.

Front 36

Subjective Data

Back 36

Information from the patient's point of view including feelings, perceptions and concerns obtained through interviews.

Hint 36

Symptoms

Front 37

Objective Data

Back 37

Observable and measurable data obtained through observation, physical examination and laboratory / diagnostic testing.

Hint 37

Signs

Front 38

Reverse Chronological Order

Back 38

Means that the most recent document is placed on the top or in front of the others. All the other documents will be at the back or the bottom of the pile.

Front 39

PPRs

Back 39

Paper-based Patient Records

Front 40

EMRs

Back 40

Electronic Medical Records

Front 41

Format

Back 41

PPR that is organized is known as _________.

Front 42

Source Orientated Record

Back 42

The documents are organized into sections based on Department.

Front 43

Problem Oriented Record

Back 43

Are organized according to the patient's health problems.

Hint 43

POR

Front 44

Problem List

Back 44

Is defined as any patient condition that requires observing diagnostic, management or patient education

Front 45

SOAP

Back 45

subjective data, objective data, assessment from the physician's point of view, plan / proposed treatment plan.

Front 46

Chief Complaint

Back 46

Identifies the patient's reason for seeking care, that is the symptom causing as a patient in the most trouble.

Hint 46

CC

Front 47

Present Illness

Back 47

Is an expansion of the chief complaint and includes a full description of the patients current illness from the time of its onset.

Hint 47

PI

Front 48

Physical Therapy

Back 48

Involves the use of therapeutic exercise, thermal modalities, cold, hydrotherapy / electrical stimulation, massage and other physical means.

Front 49

Occupational Therapy

Back 49

Helps the patient learn new skills to adapt to a physical, developmental, emotional or mentally disabling condition.

Front 50

Speech Therapy

Back 50

Treatment for the correlation of a speech impairment resulting from birth, disease, injury or prior medical treatment.

Front 51

COD

Back 51

Cause of Death

Front 52

Past History

Back 52

A review of the patient's medical status which includes, major illnesses, current medications, childhood diseases, unusual infections, accidents and injuries, hospitalization and operations, previous medical tests, immunizations, allergies.

Front 53

Family History

Back 53

Is a review of the health status of the blood relatives.

Front 54

Familial Disease

Back 54

A disease that occurs in or affect blood relatives more frequently than would be expected by chance.

Front 55

Social History

Back 55

The section of the health history includes information on the patient's lifestyle, such as health habits and living environment. Includes education, occupation, living environment, diet, personal history, exercise, sleep patterns, use of tobacco alcohol / drugs or traveled to foreign countries.

Front 56

Review of Systems

Back 56

Is a systematic review of each body system in order to detect any symptoms that have not yet been revealed.

Hint 56

ROS

Front 57

Charting

Back 57

The process of making written entries about a patient in the medical record and is performed by medical office Personnel who are directly involved with the health care of the patient.

Front 58

Symptom

Back 58

Is any change in the body or its functioning that indicates the presence of a disease.

Front 59

Subjective Symptom

Back 59

Is one that is felt by the patient and cannot be observed by another person.

Hint 59

Example: pain&nausea

Front 60

Objective Symptom

Back 60

Is one that can be observed by another person, as well as by the patient.

Hint 60

Rash, Coughing and Cyanosis are Examples

Front 61

Inpatient

Back 61

A patient who has been admitted to the hospital for at least one overnight stay.