HS111 Chapter Notes - Chapter chapter 2: Electronic Health Record, Human Body Temperature, Medical Record

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19 Oct 2021
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Medical records are important in patient cares. Electronic health record (ehr) - information contained in a patient"s records ( roadmap to patients health history. Subjective - how a patient experiences and personally describes patients problem as well as personal and family medical histories. Assessment - diagnosis, identification of a problem, or an list of possibilities. Plan - based off of the assessment this is the action we take next. Acute - just started recently or is a sharp, severe symptom. Chronic - has been going on for a while now. Afebrile - to not have a fever. Progressive - more and more each day. Non contributory - not related to this specific problem. Lethargic - a decrease in level of consciousness ; in a medical record, this is generally an indication that the patient is really sick. Genetic/ hereditary - it runs in the family. Anatomic position - a person standing facing forward, arms at the side with palms forward.

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