Medical Records & Reports

Question 1

Diagnostic Report

Answer 1

Medical report to detail the results of any test aiding in diagnosing a patient’s condition

Question 2

Immunization Record

Answer 2

The portion of a patient’s medical record which contains information about immunization history such as type of vaccine received, adverse reactions, and the date of administration

Question 3

Medical Record

Answer 3

Medical document providing a comprehensive view of an individual’s health information and medical history

Question 4

Medical Report

Answer 4

Medical document for a specific purpose, test, or visit

Question 5

Narrative Note

Answer 5

Method to write a medical summary which organizes information into chronological order and tells the patient’s story, such as how treatment has changed over time

Question 6

Pathology Report

Answer 6

Medical report to analyze a removed specimen of tissue

Question 7

Prescription Record

Answer 7

Portion of a patient’s medical record which contains information about medication history such as prescriptions, dosages, and durations

Question 8

Radiology Report

Answer 8

Medical report which contains information about the results of imaging tests

Question 9

SOAP Note

Answer 9

Method of writing a medical summary which saves time, organizes information, and prevents excess writing; the acronym SOAP stands for subjective, objective, assessment and plan

Question 10

Screening Report

Answer 10

Medical report based on screening tests for detection of diseases or disorders in patients

Question 11

Surgical Report

Answer 11

Medical report which contains information about a patient’s surgery and surgical history