Chapter 1 Medical Setting Flashcards
History and Physical
Written or dictated by admitting physician; details patient’s history, results of physician’s examination, initial diagnoses, and physician’s plan of treatment.
Physician’s Orders
Complete list of care, medications, tests, and treatmensts physician orders for patient.
Nurse’s Notes
Record of patient’s care throughout the day; includes vital signs, treatment specifics, patient’s response to treatment, and patient’s condition.
Physician’s Progress Notes
Physician’s daily record of patient’s condition, results of physician’s examinations, summary of test results, updated assessment and diagnoses, and further plans for patient’s care.
Consultation Reports
Reports given by specialists when physician has asked to evaluate patient.
Ancillary Reports
Reports from various treatments and therapies patient has received, such as rehabilitation, social services, or respiratory therapy.
Diagnostic Reports
Results of diagnostic tests performed on patient, principally from clinical lab (e.g., blood tests) and medical imaging (e.g., X-rays and ultrasound).
Informed Consent
Document voluntarily signed by patient or a responsible party that clearly desrcibes purpose, methods, procedures, benefits, and risks for a diagnostic or treatment procedure.
Operative Report
Report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical procedure itself, and how patient tolerated procedure.
Anesthesiologist Report
Relates details regarding substances (such as medications and fluids) given to patient, patient’s response to anesthesia, and vital signs during surgery.
Pathologist’s Report
Report given by pathologist who studies tissue removed from patient (e.g., bone marrow, blood, or tissue biopsy).
Discharge Summary
Comprehensive outline of patient’s entire hospital stay; includes condition at time of admission, admitting diagnoses, test results, treatments and patient’s response, final diagnosis, and follow-up plans.
Acute Care or General Hospitals
Provide services to diagnose (laboratory, diagnostic imaging) and treat (surgery, medications, therapy) diseases for a short period of time; in addition they usually provide emergency and obstetrical care.
Specialty Care Hospitals
Provide care for very specific types of diseases (e.g., psychiatric hospital).
Nursing Homes or Long-Term Care Facilities
Provide long term care for patients needing extra time to recover from illness or injury before returning home or for persons who can no longer care for themselves.
