M4 - types of documents Flashcards by Jennifer Haslbeck

Q

patient registration record

A

administrative

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Q

consents / authorizations

A

administrative

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Q

property / valuables list

A

administrative

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Q

transfer / referral form

A

administrative

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Q

death / birth certificates

A

administrative

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Q

surgical booking form

A

administrative

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Q

anaesthesia record

A

operative

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Q

operative report

A

operative

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Q

pathology report

A

operative

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Q

recovery room record

A

operative

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Q

pre-op nursing checklist

A

operative

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Q

operating room record (nursing)

A

operative

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Q

surgical count sheet (nursing)

A

operative

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Q

discharge summary

A

physician

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Q

discharge summary narrative

A

physician

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Q

emergency record

A

physician

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Q

problem list

A

physician

Q

history & physical exam

A

physician

Q

progress notes

A

physician

Q

progress notes

A

physician

Q

physician’s orders

A

physician

Q

consultation report

A

physician

Q

acute pain assessment

A

physician

Q

cardiac arrest

A

physician

Q

nursing notes

A

nursing

Q

graphic record / flow sheets

A

nursing

Q

fluid balance record

A

nursing

Q

medication sheet

A

nursing

Q

special care units

A

nursing

Q

Therapies (PT/OT/Speech)

A

ancillary/interdisciplinary

Q

dietician / nutritionist

A

ancillary/interdisciplinary

Q

social services

A

ancillary/interdisciplinary

Q

radiation therapy

A

ancillary/interdisciplinary

Q

pulmonary function

A

ancillary/interdisciplinary

Q

respiratory therapy

A

ancillary/interdisciplinary

Q

blood crossmatch/administration

A

ancillary/interdisciplinary

Q

imaging reports (xray/nuc med/ultra)

A

diagnostic reports

Q

echocardiograms

A

diagnostic reports

Q

laboratory reports

A

diagnostic reports

Q

ecg / eeg / emg

A

diagnostic reports

Q

pathology report

A

diagnostic reports

Q

autopsy report

A

diagnostic reports