Across
- 3. What the physician deems will be the best course for the patient's health
- 4. any documentation relating to a health-care client
- 5. a legal health record in digital format that contains patient health information collected by one or more care providers
- 6. what the physician gains from the exam and diagnosis
- 7. information pertaining to someone's physical or mental health, condition, or infirmary
- 9. any surgical procedure will generate this type of report that is to be kept in the patient chart
- 11. refers to anything the client says to describe their problem
- 12. accumulation of essential information from an individual's electronic medical record
Down
- 1. documentation that occurs each time the client has an encounter with the health-care provider. Must be present in the chart for every visit
- 2. starts with answers to the history questionnaire and is updated periodically to provide a cumulative view of the patient's history and current health status
- 8. what the examiner observes/sees, generally refers to physical cues
- 10. review and reorganize to remove outdated or unnecessary items not longer actively needed to provide care for patient.
- 13. questionnaire that the patient is asked to complete, usually on the first visit to the providers office