Chapter 2 - Heath Record Sections/Types of Heath Records Flashcards
Chief complaintThe main reason for the patient’s visit
Chief complaint
The story of the patient’s problem
History of present illness
Description of individual body systems in order to discover any symptoms not directly related to the main problem
Review of systems
Other significant past illnesses, like high blood pressure, asthma, or diabetes
Past medical history
Any of the patient’s past surgeries
Past surgical history
Any significant illnesses that run in the patient’s family
Family history
A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
Social history
Documents a patient visit in an office setting
Clinic Note
Documents sent to a primary physician, usually by a specialist, to give an opinion on a more challenging problem
Consult Note
Documents a patient’s emergency department visit
Emergency Department Note
Documents a patient’s admission to the hopital
Admission Summary
Documents a patient’s admission and hospital stay (usually a longer stay)
Discharge Summary
Documents a surgery
Operative Report
Documents a patient’s progress during a daily hospital visit
Daily Hospital Note/ Progress Note
Documents an imaging procedure by a radiologist
Radiology Report
