Chart Content/Healthcare Setting Flashcards
Combining Form
Consists of the word root and its combining vowel written in a word root/vowel form.
Medical Record
Documents the details of a patient’s hospital stay.
Electronic Medical Record (EMR)
A software program used to enter patient information into a computer which then organizes and stores the information.
History and Physical
This is written by the admitting physician and details the 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 treatments that the physician orders for the patient.
Nurse’s Notes
A record of the patient’s care throughout the day; includes vital signs, treatment specifics, patient’s response to treatment, and their 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 diagnosis, and further plans for care.
Consultation Reports
Reports given by specialists whom the physician has asked to evaluate the patient.
Ancillary Reports
Reports from various treatments and therapies that the patient has received, such as rehabilitation, social services, or respiratory therapy.
Diagnostic Reports
Results of diagnostic tests performed on the patient, principally from clinical lab (e.g., blood tests) and medical imaging (e.g., X-rays and ultrasound).
Informed Consent
Document voluntarily signed by the patient or a responsible party that clearly describes purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure.
Operative Report
Report from the surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of 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, patient’s response to anesthesia, and vital signs during surgery.
Pathologist’s Report
Report given by pathologist who studies tissue removed from the patient (e.g., bone marrow, blood, or tissue biopsy).
Discharge Summary
Comprehensive outline of the patient’s entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and the patient’s response, final diagnosis, and follow-up plans.
