Health Records Flashcards
chief complaint
the main reason for the patients visit
history of present illness
the story of the patients problem
review of systems
description of the individual body systems in order to discover any symptoms not directly related to the main problem
past medical history
other significant past illnesses, like high blood pressure, asthma or diabetes
past surgical history
any of the patients past surgeries
family history
any significant illnesses that run in the patients family
social history
a record of habits like smoking, drinking, drug abuse and sexual practices that can impact health
clinic note comes from a
clinic
a clinic note documents a
visit
a consult note comes from a
clinic or hospital
a consult note provides an
expert opinion on a more challenging problem
a emergency department note comes from a
emergency department
a emergency department note documents an
emergency department visit
a admission summery comes from a
hospital
a admission summary documents the
admission of a patient to the hospital
a discharge summary comes from a
hospital
a discharge summary describes
when and why the patient was admitted ; documents a longer stay
an operative report comes from a
surgeon
an operative report documents a surgery in detail
surgery in detail
a daily hospital note/ progress note comes from a
inpatient health care facility
a daily hospital note/ progress note documents
a daily hospital visit
a radiology report comes from a
radiologist
a radiology report explains
reason for image, how an image was preformed, what was seen on image, radiologists assessment and sometimes a recommendation
a pathology report comes from a
pathologist
