Understanding Medical Record Items Flashcards

Generally the first thing you find in a medical record. It contains the member info such as Name, DOB, Age, Weight, Height, Address, SSN, Sex, Marital Status, Emergency Contact info, etc

Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned.

Progress notes in an in-hospital setting are recorded daily. Those in a clinic or office setting are usually preceded by an episodic or interval history and are recorded as accounts of each visit.

A summary of several changing factors, especially the patient's vital signs or weight and the treatments and medications given.

In labor the flow sheet displays the progress of labor, including centimeters of cervical dilation, cervical effacement, position of the baby's head, baby's heart rate, frequency of contractions, mother's temperature and blood pressure, and medications given or procedures performed.

Notes dictated by a physician other than the attending physician or PCP. You will find this in the patient record if they were referred to another physician, typically a specialist.

A complete account of all past and present medical events and problems a person has experienced, including psychiatric illness. A physical examination is an evaluation of the body and its functions using inspection, palpation (feeling with the hands), percussion (tapping with the fingers), and auscultation (listening). A complete health assessment also includes gathering information about a person's medical history and lifestyle, doing laboratory tests, and screening for disease.

A list of problems to be overcome in a particular patient.

A listing of all medications the patient is taking or has taken.

These surgical reports are usually dictated, but in some cases may be found on a progress note. Occasionally the physician will write a brief Progress Note immediately after performing a procedure and then dictate a more comprehensive note at another time. Often Operative Reports are highly detailed and technical in nature.

This document contains a summary of the patient’s history and admission, the overall course of hospitalization, including the course of treatment, response to treatment, and the patient’s status upon discharge. Any follow-up planning and future care are also included.