Health Records Flashcards
Chief Complaint
The main reason for the patient’s visit
History of Present Illness
The story of the patient’s problem
Review of Systems
Description of individual body systems in order to discover any symptoms not directly related to the main problems
Past Medical History
Other significant past illnesses
like high blood pressure, asthma, or diabetes
Past Surgical History
Any of the patient’s past surgeries
Family History
Any significant Illnesses that run in the patient’s family
Social History
A record of habits that can impact health
smoking, drinking, drug abuse, and sexual practices
Clinic Note
Documents a visit
Consult Note
Provides an expert opinion on a more challenging problem
Emergency Department Note
Documents an Emergency department visit
Admission Summary
Documents the admission of a patient to the hospital
Discharge Summary
Describes when and why the patient was admitted; documents a longer stay
Operative Report
Documents a surgery in detail
Daily Hospital Note/Progress Note
Documents daily hospital visit
Radiology Report
Explains reason for image, how image was performed, what was seen on image, radiologist’s assessment; sometimes a recommendation
