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Cards In This Set
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Medical record or chart
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Documents the details of a patient's hospital stay
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History and physical
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Written or dictated by the admitting physician; details the patient's history, results of the physician's examination, initial diagnoses, and physician's plan of treatment
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Physician's orders
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Complete list of the care, medications, tests, and treatments the physician orders for the patient
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Nurse's notes
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Record of the patient's care throughout the day; includes vital signs, treatment specifics, patient's response to treatment, and patient's condition
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Physician's progress notes
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Physician's daily record of the patient's condition, results of the physician's examinations, summary of test results, updated assessment and diagnoses, and further plans for the patient's care
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Consultation reports
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Reports given by specialists whom the physician has asked to evaluate the patient
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Ancillary reports
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Reports from various treatments and therapies the patient has received, such as rehabilitation, social services, or respiratory therapy
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Diagnostic reports
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Results of diagnostic tests performed on the patient, principally from the clinical lab (for example, blood tests) and medical imagine (for example, x-rays and ultrasound)
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Informed consent
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Document voluntarily signed by the patient or a responsible party that clearly describes the purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure
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Operative report
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Report from the surgeon detailing an operation; includes a pre- and postoperative diagnosis, specific details of the surgical procedure itself, and how the patient tolerated the procedure
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Anesthesiologist's report
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Relates the details regarding the substances (such as medications and fluids) given to a patient, the patient's response to anesthesia, and vital signs during surgery
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Pathologist's report
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Report given by a pathologist who studies tissue removed from the patient (for example, bone marrow, blood, or tissue biopsy)
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Discharge summary
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Comprehensive outline of the patient's entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans
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Acute care or general hospital
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Provide services to diagnose (laboratory, diagnostic imaging) and treat (surgery, medications, therapy) diseases for a short period of time; in addition, they usually provide emergency and obstetrical care
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Specialty care hospitals
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Provide care for very specific types of diseases; for example, a psychiatric hospital
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