From Chapter 1 Flashcards Preview

Medical Scribe > From Chapter 1 > Flashcards

Flashcards in From Chapter 1 Deck (27):
0

Caveat

An acceptable reason as to why the physician is unable to obtain a patients complete history

1

Condition

An update about the status of the patients symptoms upon reevaluation or discharge

2

Diagnosis

What the doctor has determined to be the cause of the patients symptoms

3

Disposition

Where the patient will be going after leaving the medical facility

4

Course notes

A chronological timeline of what occurred during a patients stay in the medical facility

5

Chief complaint

The primary reason the patient came to see the physician

6

Location

The physical location of the pain

7

Duration

The amount of time that has passed since the pain or symptom began

8

Timing

The frequency of the pain or symptoms

9

Quality

The type of pain

10

Severity

The intensity of the pain

11

Modifying factors

What makes the pain better or worse

12

Associated symptoms

Symptoms related to the chief complaint

13

EKG

A test that checks for problems with the electrical activity of the heart

14

Family history

Contains the hereditary conditions of the patients family members

15

History of present Illness (hpi)

A logical story of what lead the patient to come to the medical facility

16

Labs

Tests performed on body fluids and excretions in order to get information about the health of a patient

17

Medical history

Includes anything pertaining to the patients personal medical history (including preexisting conditions or surgeries)

18

Orders

Directions given by the doctor to perform tests or administer treatment or medication

19

Past medical, family, social history (pfsh)

Where you would document the patients personal medical, surgical, family and social history

20

Physical examination (pe)

The objective process by which a doctor investigates a patients body for signs of disease

21

Prescription

A written document given to a patient authorizing a medicine or treatment

22

Procedures

Actions performed by the physician during a patients stay in the medical facility, usually as part of treatment for the patients presenting problem (chief complaint)

23

Radiology

The use of imaging to both diagnose and treat disease within human body

24

Review of systems (ros)

Where you would document all of the patients other symptoms (positive and negative) that are not related to the chief complaint

25

Social history

An age appropriate review of the patients past and current activities

26

Vital signs

Indicators that may be watched measures and monitored to check an individual's level of physical functioning