Arlets Crossword

4. medical term used to describe a patient who does not follow the medical advice he or she receives
8. process of recording information in the medical record
11. patient information is arranged within the chart of medical record according to who supplied the data
13. brief and to the point
15. includes a record of the patient's past medical history
19. requires that all original documents be maintained in the patient's medical record
20. specific information required of a population

1. data comes from the physician
2. transforming spoken notes into accurate written form
3. when you use precise descriptions
5. the diagnosis or impression of a patient's problem
6. when all entries in patient records are dated to show the order in which they are made
7. subjective, or internal, conditions felt by the patient
9. altering something to meet individual specifications
10. treatment cannot be discussed with parents without permission
12. includes treatment option
14. data comes from the patient
16. examine and review a group of patient records for completeness and accuracy
17. objective, or external factors like blood pressure and rashes
18. contain important information about a patient's medical history and present condition