worksheet 1F

diagnostic reports

results of diagnostic tests performed on the patient principally from the clinical lab and medical imaging

history and physical

written or dictated by the admitting physician

physicians orders

complete list of the care, medications, tests, and treatment the physician orders for the patient

discharge summary

comprehensive outline of the patients entire hospital stay

physicians progress notes

physician's daily record of the pts. condition, results of the physician's daily record of the examinations, summary of test results, updated assessments and diagnosis and further plans

nurses notes

record of the patients care throughout the day

anesthesiologist's report

relates the details regarding the substances given to a patient, patients responses, vital signs during surgery

operative report

report from the surgeon detailing on the operation

ancillary reports

reports from various treatments and therapies the patients has received

pathologist's report

reports given by a pathologist who studies tissue removed from the patient

consultation reports

reports given by specialists who the physician has asked to evaluate the pt.

informed consent

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