Card Set Information
The Patient Record/The Medical Record
To show a mutual relationship
The determination of the nature\ cause of a disease.
To see or understand a difference between two things.
Being an indispensable part of a whole.
A complete set of information put down in writing to authenticate evidence of facts and events.
A permanent legal document formally stating the results of an examination.
Preceptible to the observer\external senses (i.e. Dr's conclusions).
An inference from what has been seen or heard.
Competency as a result of training & experience.
The forecast of the outcome of a disease\injury.
Records of patient visits, phone calls, progress & treatment that are inserted into the pts. chart.
Any objective evidence of disease discoverable by a Dr. on examination of a patient.
Findings perceptible only by the affected person.
Any perceptible change in the body or its functions (Indicating disease or illness).