Answer Happy

Perm KEY TERM ASSESSMENT Directions: Match cach kryterm with its definition Q 1. Attending physician collection of subjective data about a patient 1 2. Chief complaint A narrative report of an opinion about a patient's condition by a B 3. Consultation report practitioner other than the attending physician c. Any condition that requires further observation, diagnosis, N 4. Diagnosis management, or patient education R 5. Diagnostic procedure A picture that is stored electronically to allow viewing on a D6. Digital image computer 7. Discharge summary The process of making written or electronic entries about a report patient in the medical record E 8. Documenting The way a medical record is organized X 9. Electronic health Any change in the body or its functioning that indicates the record (EHR) presence of disease P 10. Familial H. Progress notes including the following categories: subjective, 11. Flow sheet objective, assessment plan А A 1. A medical record in paper form 12. Health history W 13. Home health care A brief summary of the significant events of a patient's hospitalization 5 14. Inpatient K. A written record of the important information regarding a patient K 15. Medical record L. A paper document or electronic screen that allows similar data to F 16. Medical record be recorded and viewed chronologically format M. Arranging documents with the most recent document on top or ✓ 17. Objective symptom in the front 18. Paper-based patient The scientific method of determining and identifying a patient's condition record 19. Physical examination O. A report of the objective findings from the physician's assessment of each body system 20. Problem P. Occurring in or affecting members of a family more frequently 21. Reverse chronological than would be expected by chance order The physician responsible for the care of a hospitalized patient 22. SOAP A procedure performed to assist in the diagnosis, management, U 23. Subjective symptom or treatment of a patient's condition 24. Symptom A patient who has been admitted to the hospital for at least one overnight stay T. A statement of the most important symptom or symptoms for which a patient is seeking care A symptom felt by the patient but not observed by an examiner A symptom that can be observed by an examiner The provision of medical and nonmedical care in a patient's home or place of residence XO A computerized record of the important health information regarding a patient