Contents of Medical Chart

Question 1

DEFINITION

a narrative or record of past events and circumstances that are or may be relevant to a patient’s current state of health

Answer 1

medical chart

Question 2

The medical chart is a _________________ statement of facts pertaining to past and present health gathered, ideally from the patient

Answer 2

comprehensive

Question 3

What are the 9 contents of Medical History

Answer 3

1. patient demographic
2. chief complaint (CC)
3. history of present illness (HPI)
4. family history (FH)
5. social history (SH)
6. allergies
7. medication history
8. review of systems (ROS)
9. physical exam (PE)

Question 4

This contains the px name, age, gender, status, address, and religion

Answer 4

patient demographic

Question 5

Indicate the reason of admission to the hospital in the words of the informant

Answer 5

CC

Question 6

A chronologic description of the development of the Pt’s present illness

Answer 6

HPI

Question 7

Includes the patient’s prior illnesses, past treatments, and all medical and surgical hospitalization

Answer 7

past medical history

Question 8

present health or cause of death of parents, brothers, sisters

Answer 8

family medical history

Question 9

includes the patient’s marital status, past & present occupations, travel, hobbies, stresses, diet, habit, and use of tobacco, alcohol, or drugs

Answer 9

SH

Question 10

List any medications prescription, including over- the-counter medications, home remedies, vitamins, and supplements as well

Answer 10

past Medication, allergies and immunization

Question 11

An organized and complete examination of a Pt’s organ systems

Answer 11

review of systems

Question 12

Includes the patient’s “inventory” of signs and/or symptoms

Answer 12

review of systems

Question 13

T/F: ROS are most often answers to questions asked by the provider in order to establish a working diagnosis

Answer 13

T

Question 14

Evaluation of the body and its functions using inspection, palpation, percussion, and auscultation

Answer 14

PE

Question 15

PE includes ______________ and ____________________

Answer 15

vital signs and general examinations

Question 16

marching orders of the attending physician as regards tests, medication, and treatment

Answer 16

physician orders

Question 17

generic term for any test regarded as having value in assessing health or disease states

Answer 17

laboratory test

Question 18

examples of laboratory test

Answer 18

1. CBC (complete blood count)
2. lipid profile
3. basic metabolic panel
4. liver panel
5. TSH (thyroid-stimulating hormone)
6. urinalysis

Question 19

Document that contains the diagnosis determined by examining cells and tissues under a microscope

Answer 19

pathology report

Question 20

Purpose of nurse’s notes

Answer 20

to document…
1. a baseline nursing history and assessment for the patient
2. accomplishment of tests, treatments, and nursing orders

Question 21

temperature, pulse rate, respiratory rate, and blood pressure

Answer 21

vital signs

Question 22

A report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional

Answer 22

medication and administration records

Question 23

regular notes on the patient’s status by the interdisciplinary care team

Answer 23

progress notes

Question 24

Any health care condition that requires diagnostic, therapeutic, or educational action

Answer 24

problem list

Question 25

a written document that outlines the proposed goals, and methods of therapy

Answer 25

plan

Question 26

Contains final instructions for the patient

Answer 26

discharge summary

Question 27

Summation of all activities during the patient’s course of hospitalization

Answer 27

discharge summary

Question 28

Discharge summary contains updated health summary fields for allergy, ____________________, current medications, and lifestyle risks

Answer 28

current past medical history

Question 29

used to direct to a source for help or information

Answer 29

referral form

Question 30

used to submit (a matter in dispute) to a medical specialist/s for arbitration, decision, or examination

Answer 30

referral form

Question 31

What are the contents of a surgical form?

Answer 31

1. Pre-operating diagnosis
2. Procedure/s to be done
3. Findings
4. Details Recommendation

Question 32

any measurable fluid that goes into the patient’s body

Answer 32

intake

Question 33

intake may also pertain to (3) things

Answer 33

1. fluids
2. “solids” composed primarily of liquids
3. fluids introduced through IV

Question 34

What are the output-measurable fluids that come from the body?

Answer 34

1. urine
2. drainage
3. vomitus (matter vomited)
4. stools (fecal discharge from the bowels)

Question 35

notes from specialized diagnosticians or care providers

Answer 35

consultations

Question 36

includes permissions signed by patient for procedures, tests, or access to chart

Answer 36

consents

Question 37

T/F: Consents do not contain releases like the release signed by the patient when leaving the facility against medical advice (AMA)

Answer 37

F

Question 38

comprehensive written summary of all regular medicines taken by a patient

Answer 38

patient medication profile (PMP)

Question 39

What are the contents of PMP?

Answer 39

1. standing medications
2. stat medications
3. IV medications

Question 40

current medication list of the patient

Answer 40

standing medications

Question 41

drugs for emergency purposes

Answer 41

stat medications

Question 42

current IV therapy of the patient

Answer 42

IV medications