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Chapter 3

key
Horizontales
Documentation of clinical observations
A concise account of the patients illness, course of treatment, and condition at the time of discharge
Description of the exam of the patients body after he or she has died
Summary of the patients problems with a detailed plan for intervention
Where the patient record begins
Documents the clinical opinion of a physician other than the primary or attending physician
Assumed when a patient voluntarily submits to treatment
Record that is both paper and electronic
Consent that is either spoken or written
Documents the patients current complaints & symptoms, and past medical, personal and family history
State or county regulations that healthcare facilities must meet to be permitted to provide care
Verticales
Standardized patient assessment instrument used in home health care
Type of patient care that focuses on symptom management rather than life prolonging measures
Written document that provides directions about a patients desires in relation to care decisions if the patient is incapacitated
Group that focuses on accreditation of rehabilitation programs and services
Instructions given by physicians to other healthcare professionals
Dictated by a pathologist after an examination of tissue
Minimum Data Set