The Medical Record

Reports from various treatments and therapies that patient has received, such as rehabilitation, social services, or respiratory therapy

Ancillary Reports

Relates details regarding substances given to patient, patients response to anesthesia, and vital signs during surgery

Anesthesiologists Report

Physicians orders

Complete list of care, medications, tests, and treatments physicians orders for patient

Discharge Summary

Comprehensive outline of patients entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patients response, final diagnosis, and follow up plans

Reports given by specialists whom physician has asked to evaluate patient

Consultation Reports

Results of diagnostic tests performed on patient, principally in clinical labs and medical imaging

Diagnostic Reports

Comprehensive outline of patients entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patients response, final diagnosis and follow-up plans

Discharge Summary

Informed Consent

Document voluntarily signed by patient or responsible party that clearly describes purpose, methods, procedures, benefits, and risks of diagnostic or treatment procedure

Written or dictated by admitting physician; details patients history, results of physicians examination, initial diagnoses, and physicians plan of treamtent

History and Physical

Document voluntarily signed by patient or responsible party that clearly describes the purpose, methods, procedures, benefits and risks of a diagnostic or treatment procedure

Informed consent

Record of patients care throughout the day; includes vital signs, treatment specifics, patients response to treatment, and patients condition

Nurses Notes

Report from surgeon detailing an operation; include pre- and postoperative diagnosis, specific details about the surgical procedure itself, and how patient tolerated the procedure

Operative Report

Report given by pathologist who studies tissue removed from patient

Pathologists Report

Complete list of care, medications, tests, and treatments physicians orders for patient

Physicians Orders

Physicians daily record of patients condition, results of physicians examinations, summary of test results, updated assessment, and diagnoses, and further plans for patients care

Physicians Progress Notes

Physicians Progress Notes

Physicians daily record of patients condition, results of physicians examinations, summary of test results, updated assessment and diagnoses, further plans for patient care

Nurses Notes

Record of patients care throughout the day, includes vital signs, treatment specifics, patients response to treatment, and patients condition

Anesthesiologist Report

Relates details regarding substances given to patient, patients response to anesthesia, and vital signs during surgery

Operative Report

Report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of the surgical procedure itself, and how patient tolerated procedure

Pathologists Report

Report given by pathologist who studies tissue removed from patient ( bone marrow, blood or tissue biopsy)

Ancillary Reports

Reports from various treatments and therapies patient has received, such as rehabilitation, social services, respiratory therapy

Consultation Reports

Reports given by specialists whom physician has asked to evaluate patient

Diagnostic Reports

Result of diagnostic tests performed on patient, principally from clinical lab and medical imaging

History and Physical

Written by admitting physician, detials of patient history, results of physicians examination, initial diagnoses, and physicians plan of treatment