M4 - types of documents Flashcards

1
Q

patient registration record

A

administrative

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2
Q

consents / authorizations

A

administrative

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3
Q

property / valuables list

A

administrative

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4
Q

transfer / referral form

A

administrative

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5
Q

death / birth certificates

A

administrative

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6
Q

surgical booking form

A

administrative

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7
Q

anaesthesia record

A

operative

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8
Q

operative report

A

operative

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9
Q

pathology report

A

operative

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10
Q

recovery room record

A

operative

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11
Q

pre-op nursing checklist

A

operative

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12
Q

operating room record (nursing)

A

operative

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13
Q

surgical count sheet (nursing)

A

operative

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14
Q

discharge summary

A

physician

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15
Q

discharge summary narrative

A

physician

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16
Q

emergency record

A

physician

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17
Q

problem list

A

physician

18
Q

history & physical exam

A

physician

19
Q

progress notes

A

physician

20
Q

progress notes

A

physician

21
Q

physician’s orders

A

physician

22
Q

consultation report

A

physician

23
Q

acute pain assessment

A

physician

24
Q

cardiac arrest

A

physician

25
Q

nursing notes

A

nursing

26
Q

graphic record / flow sheets

A

nursing

27
Q

fluid balance record

A

nursing

28
Q

medication sheet

A

nursing

29
Q

special care units

A

nursing

30
Q

Therapies (PT/OT/Speech)

A

ancillary/interdisciplinary

31
Q

dietician / nutritionist

A

ancillary/interdisciplinary

32
Q

social services

A

ancillary/interdisciplinary

33
Q

radiation therapy

A

ancillary/interdisciplinary

34
Q

pulmonary function

A

ancillary/interdisciplinary

35
Q

respiratory therapy

A

ancillary/interdisciplinary

36
Q

blood crossmatch/administration

A

ancillary/interdisciplinary

37
Q

imaging reports (xray/nuc med/ultra)

A

diagnostic reports

38
Q

echocardiograms

A

diagnostic reports

39
Q

laboratory reports

A

diagnostic reports

40
Q

ecg / eeg / emg

A

diagnostic reports

41
Q

pathology report

A

diagnostic reports

42
Q

autopsy report

A

diagnostic reports