MOPS

Card Set Information

Author:
shaketarenae
ID:
40916
Filename:
MOPS
Updated:
2010-10-09 19:09:05
Tags:
TERMS FALL
Folders:

Description:
The Patient Record/The Medical Record
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The flashcards below were created by user shaketarenae on FreezingBlue Flashcards. What would you like to do?


  1. CORRELATION
    To show a mutual relationship
  2. DIAGNOSIS
    The determination of the nature\ cause of a disease.
  3. DISCERNIBLE
    To see or understand a difference between two things.
  4. INTEGRAL
    Being an indispensable part of a whole.
  5. MEDICAL RECORD
    A complete set of information put down in writing to authenticate evidence of facts and events.
  6. MEDICAL REPORT
    A permanent legal document formally stating the results of an examination.
  7. OBJECTIVE (info)
    Preceptible to the observer\external senses (i.e. Dr's conclusions).
  8. OBSERVATION
    An inference from what has been seen or heard.
  9. PROFICIENCY
    Competency as a result of training & experience.
  10. PROGNOSIS
    The forecast of the outcome of a disease\injury.
  11. PROGRESS NOTES
    Records of patient visits, phone calls, progress & treatment that are inserted into the pts. chart.
  12. SIGN
    Any objective evidence of disease discoverable by a Dr. on examination of a patient.
  13. SUBJECTIVE
    Findings perceptible only by the affected person.
  14. SYMPTOM
    Any perceptible change in the body or its functions (Indicating disease or illness).

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