Health Providers
Who is a HC provider who graduated medical school?
Physician
A Physician who can operate or complete invasive procedures?
Surgeon
The story of the patients problem
History of present illness
A hand written or or electronic note made in an office setting
Clinic note
ER
Emergency room
Who is trained to assess and treat problems with speech and swallowing?
Speech and Language Pathologist
A Physican with special training in caring for children
Pediatrician
Significant illness that runs in patient's family
family history
A note that describes what was seen on an image
Radiology report
VS
vital signs
Trained in evaluating the nutritional status of a patient and develop a diet plan?
Dietician
A physician trained in evaluating the cause and effects of disease?
Pathologist
The main reason for the patient's visit
Chief complaint
A note completed by a surgeon
Operative Note
Post Op
after surgery
An advanced level nurse who can provide care planning and education to patients
Registered Nurse
Physician with training in pain sedation and pain control
Anesthesiologist
Record of habits like smoking and drinking.
Social history
A note that details when and why a patient was admitted
Discharge summary
PMHx
Past medical history
Specialist in the cause of diseases and the use of this data to enhance public health?
Epidemiologist
Trained in the removal of blood from the body for diagnostic purposes?
Phlebotomist
Description of individual body systems
Review of systems
A note that does not follow the SOAP format
Prescription
SOB
shortness of breath