Term
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Definition
| A patient who has been admitted to a hospital for at least one overnight stay. |
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Definition
| Conclusions drawn by the physician from an interpretation of data. |
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Term
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Definition
| A written record of important information regarding a patient, including the care of that individual and the progress of the patients condition. |
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Term
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Definition
| The way a medical record is organized. |
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Term
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Definition
| A symptom that can be observed by an examiner. |
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Term
| Paper-Based patient Record (PPR) |
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Definition
| A medical record in paper form. |
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Term
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Definition
| An individual receiving medical care. |
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Term
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Definition
| An assessment of each part of the patients body to obtain objective data about the patient that assists the physician in determining the patients state of health. |
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Term
| Physical Examination Report |
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Definition
| A report of the objective findings from the physicians assessment of each body system. |
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Term
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Definition
| Any condition that requires further observation, diagnosis, management, or pateint education. |
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Term
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Definition
| The probable course and outcome of a disease and the prospects for a patients recovery. |
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Term
| Reverse Chronological Order |
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Definition
| Arranging documents with the most recent document on top or in the front, which means that the oldest document is on the bottom or at the back of a section or file. |
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Term
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Definition
| A method of organization for recording progress notes.The SOAP format includes the following categories;subjective data, objective data,assessment and plan. |
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Term
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Definition
| A symptom that is felt by the patient but is not observable by an examiner. |
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Term
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Definition
| Any change in the body or its functioning that indicates the presence of disease. |
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