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Medical Terminology: Medical Records & Documentation Part 1
This deck covers key concepts and definitions related to medical records and documentation, providing a foundational understanding of terms used in healthcare settings.
Define: Medical Record
A comprehensive document that contains a patient’s medical history, diagnoses, treatments, and other health-related information. The doctor reviewed the Medical Record to understand the patient’s previous treatments.
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Key Terms
Term
Definition
Define: Medical Record
A comprehensive document that contains a patient’s medical history, diagnoses, treatments, and other health-related information. The doctor reviewed t...
Define: Health Record
A collection of information about a person’s health, including medical history, treatments, and outcomes. The nurse updated the Health Record after th...
Define: Patient Chart
A systematic documentation of a patient’s medical history and clinical data, used by healthcare professionals for treatment planning. The physician re...
Define: Progress Notes
Notes made by healthcare providers that document a patient’s progress during treatment and any changes in their condition. The Progress Notes indicate...
Define: Encounter Note
A record of a specific patient visit, detailing the reason for the visit, findings, and recommendations. The Encounter Note summarized the patient’s s...
Define: Admission Note
A document created upon a patient’s admission to a healthcare facility that includes medical history and initial assessments. The Admission Note provi...
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| Term | Definition |
|---|---|
Define: Medical Record | A comprehensive document that contains a patient’s medical history, diagnoses, treatments, and other health-related information. The doctor reviewed the Medical Record to understand the patient’s previous treatments. |
Define: Health Record | A collection of information about a person’s health, including medical history, treatments, and outcomes. The nurse updated the Health Record after the patient’s last visit. |
Define: Patient Chart | A systematic documentation of a patient’s medical history and clinical data, used by healthcare professionals for treatment planning. The physician referred to the Patient Chart to assess the patient’s progress. |
Define: Progress Notes | Notes made by healthcare providers that document a patient’s progress during treatment and any changes in their condition. The Progress Notes indicated significant improvement in the patient’s recovery. |
Define: Encounter Note | A record of a specific patient visit, detailing the reason for the visit, findings, and recommendations. The Encounter Note summarized the patient’s symptoms and the doctor’s advice. |
Define: Admission Note | A document created upon a patient’s admission to a healthcare facility that includes medical history and initial assessments. The Admission Note provided essential background information for the attending physician. |
Define: Discharge Summary | A report that summarizes a patient’s hospital stay, including diagnoses, treatments, and follow-up care recommendations. The Discharge Summary outlined the patient’s care plan after leaving the hospital. |
Define: H&P (History and Physical) | A comprehensive document that includes a patient’s medical history and the results of their physical examination. The surgeon reviewed the H&P before proceeding with the operation. |
Define: Flow Sheet | A tool used to document patient data over time, often in a graphical format, to monitor progress and treatment outcomes. The nurse used a Flow Sheet to track the patient’s vital signs daily. |
Define: Problem List | A comprehensive list of a patient’s current medical problems, often included in their medical record for reference. The Problem List helped the healthcare team prioritize treatment plans. |
Define: Treatment Plan | A detailed outline of the strategies and interventions designed to address a patient’s specific medical issues. The doctor presented the Treatment Plan to the patient during the consultation. |
Define: Care Plan | A document that outlines the specific actions to be taken to provide care to a patient, based on their needs and goals. The Care Plan was adjusted to better meet the patient’s rehabilitation goals. |
Define: Narrative Note | A descriptive account of a patient’s condition, treatment, and progress, written in a free-text format. The physician wrote a Narrative Note to capture the details of the patient’s visit. |
Define: Documentation Standards | The established guidelines for how medical records should be created, maintained, and stored to ensure accuracy and compliance. The clinic adheres to strict Documentation Standards to maintain patient confidentiality. |
Define: Audit Trail | A secure record that tracks changes made to a patient’s medical record, including who made the changes and when. The Audit Trail revealed who accessed the patient’s sensitive information. |
Define: Continuity of Care Document (CCD) | A standardized document that summarizes a patient’s care over time, facilitating communication among healthcare providers. The Continuity of Care Document (CCD) was shared between the primary care physician and the specialist. |
Define: Medical History | A comprehensive account of a patient’s past health issues, treatments, and family health history. The physician gathered the Medical History to understand the patient’s background. |
Define: Review of Systems (ROS) | A systematic approach to obtaining a patient’s medical history by reviewing each body system for symptoms. During the exam, the doctor conducted a Review of Systems (ROS) to identify any underlying issues. |
Define: Differential Diagnosis (DDx) | The process of distinguishing a disease or condition from others that present similar clinical features. The doctor compiled a Differential Diagnosis (DDx) to determine the cause of the patient’s symptoms. |
Define: Chief Complaint (CC) | The primary reason for a patient’s visit to a healthcare provider, typically stated in their own words. The Chief Complaint (CC) was recorded as severe chest pain. |
Define: SOAP Note | A structured method of documentation that includes Subjective, Objective, Assessment, and Plan components of patient care. The clinician used a SOAP Note format to organize the patient’s visit information. |
Define: Subjective | The portion of a medical note that includes the patient’s personal statements about their symptoms and experiences. The Subjective section detailed the patient’s complaints and feelings about their condition. |
Define: Objective | The part of a medical note that includes measurable or observable data collected during the examination. The Objective findings showed elevated blood pressure readings. |
Define: Assessment | The healthcare provider’s evaluation of the patient’s condition based on subjective and objective data. The Assessment concluded that the patient was experiencing an exacerbation of asthma. |
Define: Plan | The proposed course of action to address the patient's condition, including treatments and follow-up appointments. The Plan included medication adjustments and a follow-up visit in two weeks. |