Medical Records Terminology Flashcards

Medical Terminology: A Living LanguageFourth EditionBonnie F. Fremgen and Suzanne S. FruchtChapter 1: Introduction to Medical TerminologyThe Medical Record & Healthcare Settings

22 cards   |   Total Attempts: 184
  

Cards In This Set

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Medical record or chart
Documents the details of a patient's hospital stay
History and physical
Written or dictated by the admitting physician; details the patient's history, results of the physician's examination, initial diagnoses, and physician's plan of treatment
Physician's orders
Complete list of the care, medications, tests, and treatments the physician orders for the patient
Nurse's notes
Record of the patient's care throughout the day; includes vital signs, treatment specifics, patient's response to treatment, and patient's condition
Physician's progress notes
Physician's daily record of the patient's condition, results of the physician's examinations, summary of test results, updated assessment and diagnoses, and further plans for the patient's care
Consultation reports
Reports given by specialists whom the physician has asked to evaluate the patient
Ancillary reports
Reports from various treatments and therapies the patient has received, such as rehabilitation, social services, or respiratory therapy
Diagnostic reports
Results of diagnostic tests performed on the patient, principally from the clinical lab (for example, blood tests) and medical imagine (for example, x-rays and ultrasound)
Informed consent
Document voluntarily signed by the patient or a responsible party that clearly describes the purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure
Operative report
Report from the surgeon detailing an operation; includes a pre- and postoperative diagnosis, specific details of the surgical procedure itself, and how the patient tolerated the procedure
Anesthesiologist's report
Relates the details regarding the substances (such as medications and fluids) given to a patient, the patient's response to anesthesia, and vital signs during surgery
Pathologist's report
Report given by a pathologist who studies tissue removed from the patient (for example, bone marrow, blood, or tissue biopsy)
Discharge summary
Comprehensive outline of the patient's entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans
Acute care or general hospital
Provide services to diagnose (laboratory, diagnostic imaging) and treat (surgery, medications, therapy) diseases for a short period of time; in addition, they usually provide emergency and obstetrical care
Specialty care hospitals
Provide care for very specific types of diseases; for example, a psychiatric hospital