Records Contain

Question 1

Discharge planning on admission ​

Physical assessment findings from anyone

Answer 1

Patient identification and demographic data​

Informed consent for treatment and procedures​

Admission data​

Nursing diagnoses or problems​

Care plans​

Record of nursing care treatment and evaluation​

Medical History​

Medical Diagnosis​

Therapeutic Orders​

Progress notes​

Physical assessment findings​

Diagnostic study findings​

Patient education​

Summary of operations​

Discharge plan and summary​