the medical record Flashcards
History and Physical
1) written or dictated by the admitting physician, details patient’s history, results of physician’s examination, initial diagnosis, and physician’s plan of treatment.
Physician’s Orders
2) complete list of all care, medications, tests, and treatments
Nurse’s Notes
3) record of patient’s care throughout the day, includes vital signs, treatment specifics, patient’s response to treatment, and patient’s condition
Physician’s Progress Notes
4) physician’s daily record of patient’s condition, results of physician’s examinations, summary of test results, updated assessment and diagnoses, and further plans for treatment.
Consulation Reports
5) reports given by specialists whom physician has asked to evalute patient
Ancillary Reports
6) reports from various treatments and therapies. patient has recieved rehabilitation, social services, respiratory therapy, or dietetics.
Diagnostic Reports
7) results or diagnostic tests performed on the patient; principally from the clinical lab (blood test) or the medical imaging department (x-rays)
Informed Consent
8) document voluntarily signed by the patient or responsible party that clearly describes purpose, methods, procedures, benefits and risks of a diagnostic, or therapeutic procedure.
Operative Report
9) report given by surgeon detailing an operation, includes pre- and post operative diagnoses, specific details of the surgical procedure itself, and how the patient tolerated the procedure.
Anesthesiologist’s Report
10) relates details regarding the substances given to the patient during surgery, how the patient tolerated anesthesia, and the vital signs during the surgery.
Pathologist’s Report
11) a report given by a pathologist who studies tissue removed from the patient. (bone marrow, blood, tissue biopsy)
Discharge Summary
12) comprehensive outline of the patient’s entire hospital stay, includes condition at admission, admitting diagnosis, test results or treatments, patient’s response, final diagnosis and follow-up plans
