Elements of the Medical Record (Chapter 1) Flashcards
State the component/element of the Medical Record
Written or dictated by admitting physician; details of patient’s history, results of physicians examination, initial diagnoses, and plan of treatment
History and Physical
List of care, meds, tests and treatments physician orders for patient
Physician’s Orders
Patients care throughout the day; includes vital signs, treatment specifics, patient’s response to treatment, and patient’s condition
Nurse’s Notes
Daily record of patient’s condition, results of physicians examinations, summary of test results, updated assessment and diagnoses, and further plans for patient’s care
Physician’s Progress notes
Given by specialists
Consultation reports
Reports from various treatments and therapies patient has received; location of rehabilitation reports
Ancillary reports
Results of diagnostic tests performed on patient, clinical lab and medical imaging
Diagnostic reports
Document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure
Informed consent
Report from surgeon; pre and post operative diagnosis, specific details of surgical procedure itself, and how patient tolerated procedure
Operative report
Relates details regarding substances (such as meds and fluids) given to patient, patients response to anesthesia, vital signs during surgery
Anesthesiologists report
Given by pathologist who studies tissue removed from patient (e.g. bone marrow, blood, or tissue biopsy)
Pathologist’s report
Written after patient care is completed; includes condition at time of admission, admitting diagnosis, test results, treatments and patients response, final diagnosis, and follow up plans
Discharge summary
