ibs Flashcards
a graph used to record the patient vital signs
graph sheet
the blank record contains an antepartum record , labor and delivery record, and postpartum record.
obstetrical
the anesthesia record documents the monitoring of the patient during the ad administrative of blank
surgical episode
the operative report contains both blank and blank diagnoses.
pre and post
the blank aids in the diagnosis and the treatment of the patient by documenting the pathologist’s analysis of tissue
pathology report
The first listed diagnoses and procedures is blank
clinical data
written instruction given by a patient to a health care provider outlining the patient’s preference for care before the need for treatment is known as an blank
advance directive
a document that provides a summary of a patient’s hospitalization is an blank
Clinical resume
A chronological description of the patients present condition from the time of onset to the present is a blank
history of the present illness
preprinted orders that are placed on a patients record are called what
Physician orders pre-approved by the medical staff which are pre-printed and placed on the patient’s record.
the completion of an H an H&PE is the responsibility of the blank
attending physician
a tissue report is also known as
Pathology reports
a report documenting blood chemistry, blood gases and blood types is a
laboratory report
all the patient information obtained through treatment and care of the patient is called
clinical data
review of medical events in the patient’s family, including disease which may be hereditary
family history
