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| puncture to withdraw fluid |
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| surgically create an opening |
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| process of visually examining |
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| Medical record document written by the admitting physician. It details the patient's history, results of the physician's examination, initial diagnoses, and physician's plan of treatment. |
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| Medical record document that contains a complete list of the care, medications, tests, and treatments the physician orders for the patient. |
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| Medical record document that records the patient's care throughout the day. It includes vital signs, treatment specifics, patient's response to treatment, and patient's condition. |
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| Documents in a patient's medical record. They are the reports given by specialists who the physician has requested to evaluate the patient. |
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| Reports in a patient's medical record from various treatments and therapies the patient has received, such as rehabilitation, social services, respiratory therapy, or from the dietician. |
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| Found in a patient's medical record. It consists of the results of all diagnostic tests performed on the patient, principally from the lab and medical imaging (for example, X-ray and ultrasound) |
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| A medical record 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. |
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| A medical record report from the surgeon detailing an operation. It includes a pre- and postprocedure itself, and how the patient tolerated the procedure. |
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| anesthesiologist's report |
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| A medical record document that relates the details regarding the drugs given to a patient and the patient's response to anesthesia and vital signs during surgery. |
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| A medical record report given by a pathologist who studies tissue removed from the patient (for example: bone marrow, blood, or tissue biopsy). |
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| Part of a patient's medical record. It is a comprehensive outline of the patient's entire hospital stay. It includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans. |
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| Hospitals that provide care for very specific types of disease. A good example is a psychiatric hospital. |
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| acute care or general hospitals |
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| Hospitals that typically 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. Also called an acute care hospital. |
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| long term care facility or nursing home |
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| A facility that provides long-term care for patients who need extra time to recover from all illness or accident before they return home or for persons who can no longer care for themselves. Also called a long-term care facility. |
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| ambulatory care, surgical centers, or outpatient clinics |
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| A facility that provides services that do not require overnight hospitalization. The services range from simple surgeries, to diagnostic testing, to therapy. Also called a surgical center or an outpatient clinic. |
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| Individual or groups of physicians providing diagnostic and treatment services in a private office setting rather than a hospital. |
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| health maintenance organization (HMO) |
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| An organization that contracts with a group of physicians and other health care workers to provide care exclusively for its members. The HMO pays the health care workers a prepaid fixed amount per member whether that member requires medical attention or not. |
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| Agencies that provide nursing, therapy, personal care, or housekeeping services in the patient's own home. |
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| Facilities that provide intensive physical and occupational therapy. They include inpatient and outpatient treatment. |
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| An organized group of health care workers that provide supportive treatment to dying patients and their families. |
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