Medical Recordsssss
The process of recording information.
Documentation
Serves as a communication tool and a legal document.
Patient Medical Records.
The process of evaluating objective anatomic findings through the use of observation, palpation, percusion, and auscultation.
Physical Examination
Each condition or diagnosis a patient has is listed separately and given its own number and is put on this document.
Problem List
A form that is completed when there is an error or accident at a health care facility.
Incident Report
Information in a medical record that can be used to identify a person.
Protected Health Insurance (PHI)
Determines the identity of a disease, or illness, by a medical examination.
Diagnosis.
Temperature, pulse, blood pressure, and respirations.
Vital Signs
The primary reason the person is seeking care.
Chief Complaint
An item of additional material that is added to a health record to correct an error or to add omitted data.
Addendum
A federal law that provides confidentiality, improves access to long term care services, prevents fraud and abuse, and fights for continuity of care.
HIPPA
An inventory of body, system by system, obtained by a healthcare provider through a series of questions.
Review of Systems. (ROS)
Data that can be felt, seen, or measured.
Objective Data
Information that summarizes the reason why a person was in the hospital. It has their procedures, surgeries, tests, medications, and outcomes.
Hospital Discharge Summary
A record of the drugs or medications administered by the licensed nursing staff during a stay at a healthcare facility.
Medication Administration Record. (MAR)
A patient record in digital form.
Electronic Health Record. (EHR)
Information such as previous surgeries, known allergies and current medications.
Past Medical History
Probable outcome of a disease or injury.
Prognosis
The process by which health professionals impart information to patens and their caregivers.
Patient Education
A way of reporting infrmation that involves situation, background, assessment, and recommendation.
SBAR communication
A form that must be signed by the patient in order to provide a copy of the person's health record to themself, an insurance company, or another medical provider.
Release of Information
A type of documentation that uses subjective, objective, assessmnt, and plan data.
SOAP note
Data that comes from the patient.
Subjective Data
Includes medical care given to a patient for an illness or injury, instructions to the patient, and any medications prescribed.
Treatment Plan
A term used to describe a patient who does not follow the medical advices that he or she receives.
Noncompliant