parts of a medical record Flashcards
past and current medical conditions along with a head to toe assessment is what part of the medical record ?
history and physical
care,medications, tests, and treatments is what part of a medical record ?
physicians orders
record of all that is done for a patient is what part of the medical record ?
nurses notes
physicians ongoing record is what part of the medical record ?
physicians progress notes
A record by specialists who have seen the patient or reviewed the medical record is what part of the medical record?
consultation reports
reports of procedures or therapies by departments such as physical therapy or respiratory therapy is what part of the medical record?
ancillary reports
An important section which contains reports of tests ordered by the physician is what part of the medical records?
diagnostic reports
permission for treatment. May also include the purpose, risks, and benefits of a procedure is what part of the medical record?
informed consent
A record dictated by the physician containing all details of a specific surgical procedure is what part of the medical record?
operative report
A document of the drugs used for anesthesia and the patient’s response to them, and the surgery is what part of the medical record?
Anesthesiologists report
findings from an examination of tissue or organs removed during a surgical procedure is what part of the medical record?
pathologists report
A final record of all that occur during a patient’s hospitalization with follow up plans is what part of the medical record?
discharge summary
