Contents of Medical Chart Flashcards
DEFINITION
a narrative or record of past events and circumstances that are or may be relevant to a patient’s current state of health
medical chart
The medical chart is a _________________ statement of facts pertaining to past and present health gathered, ideally from the patient
comprehensive
What are the 9 contents of Medical History
- patient demographic
- chief complaint (CC)
- history of present illness (HPI)
- family history (FH)
- social history (SH)
- allergies
- medication history
- review of systems (ROS)
- physical exam (PE)
This contains the px name, age, gender, status, address, and religion
patient demographic
Indicate the reason of admission to the hospital in the words of the informant
CC
A chronologic description of the development of the Pt’s present illness
HPI
Includes the patient’s prior illnesses, past treatments, and all medical and surgical hospitalization
past medical history
present health or cause of death of parents, brothers, sisters
family medical history
includes the patient’s marital status, past & present occupations, travel, hobbies, stresses, diet, habit, and use of tobacco, alcohol, or drugs
SH
List any medications prescription, including over- the-counter medications, home remedies, vitamins, and supplements as well
past Medication, allergies and immunization
An organized and complete examination of a Pt’s organ systems
review of systems
Includes the patient’s “inventory” of signs and/or symptoms
review of systems
T/F: ROS are most often answers to questions asked by the provider in order to establish a working diagnosis
T
Evaluation of the body and its functions using inspection, palpation, percussion, and auscultation
PE
PE includes ______________ and ____________________
vital signs and general examinations
marching orders of the attending physician as regards tests, medication, and treatment
physician orders
generic term for any test regarded as having value in assessing health or disease states
laboratory test
examples of laboratory test
- CBC (complete blood count)
- lipid profile
- basic metabolic panel
- liver panel
- TSH (thyroid-stimulating hormone)
- urinalysis
Document that contains the diagnosis determined by examining cells and tissues under a microscope
pathology report
Purpose of nurse’s notes
to document…
1. a baseline nursing history and assessment for the patient
2. accomplishment of tests, treatments, and nursing orders
temperature, pulse rate, respiratory rate, and blood pressure
vital signs
A report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional
medication and administration records
regular notes on the patient’s status by the interdisciplinary care team
progress notes
Any health care condition that requires diagnostic, therapeutic, or educational action
problem list
a written document that outlines the proposed goals, and methods of therapy
plan
Contains final instructions for the patient
discharge summary
Summation of all activities during the patient’s course of hospitalization
discharge summary
Discharge summary contains updated health summary fields for allergy, ____________________, current medications, and lifestyle risks
current past medical history
used to direct to a source for help or information
referral form
used to submit (a matter in dispute) to a medical specialist/s for arbitration, decision, or examination
referral form
What are the contents of a surgical form?
- Pre-operating diagnosis
- Procedure/s to be done
- Findings
- Details Recommendation
any measurable fluid that goes into the patient’s body
intake
intake may also pertain to (3) things
- fluids
- “solids” composed primarily of liquids
- fluids introduced through IV
What are the output-measurable fluids that come from the body?
- urine
- drainage
- vomitus (matter vomited)
- stools (fecal discharge from the bowels)
notes from specialized diagnosticians or care providers
consultations
includes permissions signed by patient for procedures, tests, or access to chart
consents
T/F: Consents do not contain releases like the release signed by the patient when leaving the facility against medical advice (AMA)
F
comprehensive written summary of all regular medicines taken by a patient
patient medication profile (PMP)
What are the contents of PMP?
- standing medications
- stat medications
- IV medications
current medication list of the patient
standing medications
drugs for emergency purposes
stat medications
current IV therapy of the patient
IV medications
