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13 Cards in this Set
- Front
- Back
Abstracting
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extracting data from the health record
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Admission diagnosis
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diagnosis that brings the patient to the hospital;. This will often be a symptom
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Chief complaint
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the reason, in the patient's own words, for presenting to the hospital
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Comorbidities
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preexisting diagnoses or conditions that are present on admission
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Consultant
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healthcare provider who is asked to see the patient to provide expert opinion outside the expertise of the requester
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Healthcare provider
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person who provides care to a patient
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Hybrid
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a combination of formats producing similar results( i.e., paper and electronic records
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Integral
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essential part of a disease process
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Physician
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licensed medical doctor
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Principal diagnosis
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The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
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Principal procedure
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Procedure performed for definitive treatment, rather than for diagnostic or exploratory purposes, or one that was necessary to take care of a complication.
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Progress notes
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daily recordings by healthcare providers of patient progress
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Review of systems
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question and answer period that occurs between a patient and a healthcare provider during which any healthcare issues are reviewed.
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