Chap.2 - Types Of Health Records Flashcards
Chief complaint
The main reason for the patients visit
History of previous illnesses
The story of the patient’s problem.
Review of systems
Description of individual body systems in order to discover any symptoms not directly related to the main problem.
Past medical history
Other significant past illnesses, like high BP, asthma or diabetes
Past surgical history
Any of the patient’s past surgeries
Family history
Any significant illnesses that run in the patients family.
Social history
A record of habits like smoking, drinking, drug abuse and sexual practices that can impact health.
Clinic note
Anytime a health care professional sees a patient in an office setting, he or she must document this visit.
Consult note
A note from a visit to a specialist or consultant can take two general types of approaches.
(Looks Like a letter)
Emergency department note
Patients seen in emergency department ms and urgent care clinics are almost always new patients to the clinic
Admissions summary
Upon admittance to the hospital, patients must provide a medical history and receive a PE.
Discharge summary
A discharge summary note details when and why a patient was admitted.
Operative report
After each surgery, the surgeon completes an operative report that documents in detail the procedure that was performed, the events and the outcome.
Daily hospital note/progress note
Every day the patient is in the hospital, a health care professional must see him or her and document the visit.
