Chapter 1- Medical Record (EMR) Flashcards
List the Medical Record in order
- History and Physical
- Physician’s Orders
- Nurse’s Notes
- Physician’s Progress Notes
- Consultation Reports
- Ancillary Reports
- Diagnostic Reports
- Informed Consent
- Operative Report
- Anesthesiologit’s Report
- Pathologist’s Report
- Discharge Summary
Physician’s Orders:
complete list of all care, medications, tests, and treatments, and physician orders for patient
Nurse’s Notes
a record of patient care throughout the day; includes vital signs, treatment specifics, patient’s response to treatment, and the patient’s condition.
Physician’s Progress Notes:
physician’s daily record of patient’s care, results of physician’s examinations, updated assessment & diagnosis, a summary of test results, and further plans for patient care.
Consultation Reports:
eports given by specialists (highly specialized MDs) whom the physician has requested to evaluate the patient
Ancillary Reports:
reports from various treatments and therapies the patient has received such as rehabilitation, social services, or respiratory therapy.
Diagnostic Reports
Results from diagnostic tests performed on the patient; principally from the clinical lab (ex. Blood tests) and medical imaging (ex. X-ray & ultrasound).
Informed Consent:
document voluntarily signed by the patient or the responsible party that clearly describes the purpose, methods, procedure, benefits, and risks of a diagnostic or treatment procedure.
Operative Report
: report given by the surgeon who performs the operation, including pre-and post-operative specific details regarding the surgical procedure itself, and how the patient tolerated the procedure
Anesthesiologist’s Report:
Relates details regarding substances (such as
medications and fluids) given to the patient, the patient’s response to anesthesia, and vital signs during surgery
Pathologist’s Report
eport from a pathologist who studied tissue removed from the patient (bone marrow, blood, or tissue biopsy)
Discharge Summary
comprehensive outline of the patient’s entire hospital stay, patient’s condition at the time of admission, admitting diagnostic, a summary of test results, treatments, and patient’s response to treatment, final diagnostics, and follow-up plans
What are the following identification information the EMR must contain?
patient’s name, age, gender, physician, admission date, and identification number
What is a unit clerk?
when the patient is in the hospital, responsible for placing documents in proper place
What does the medical records department do?
that all documents are present, complete, signed, and in the correct order
