medical terminology- chapter 1 (medical records)

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nurse's notes

completed by nursing staff to record patient's care throughout the day; includes vital signs, treatment specifics, patient's response to treatment, patient's condition

nurse's notes

completed by nursing staff to record patient's care; vital signs, treatment specifics, patient's response to treatments, patient's condition

informed consent

document voluntarily signed by patient/responsible party; describes purpose, methods, procedures, benefits, risks of procedure(s)

operative report

from a surgeon; includes pre/post op diagnosis, specific details of procedure, how patient tolerated procedure

ancillary reports

from various treatments/therapies; may include rehab, dietetics, respiratory therapy, social services

consultation reports

given by specialist when physician asks for patient evaluation

diagnostic reports

include results of all diagnostic tests performed; after written by the lab or medical imaging department

physician's orders

ordered by doctor; provides a list of care, meds, treatments, and tests

discharge summary

outlines patient's entire hospital stay; includes condition at admission, admitting diagnosis, test results/treatments, patient's response, final diagnosis, follow-up plans

physician's progress notes

physician's daily record of patient's condition; results of physical exam, summary of test results, updated assessment/diagnosis, further plans for treatment

physician's progress notes

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 patient's care

anesthesiologist's report

provides details of drugs given during surgery; patient's response to anesthesia/vital signs during surgery

pathologist's report

report given by a pathologist who studies tissue removed from patient

history/physical

written or dictated by admitting physician; details patient's history, results of physician's examination, initial diagnoses, and physician's plan of treatment


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