Chapter 1 Elements of Medical Records
Physican's Orders
complete list of care, medications, tests, and treatments a physician orders for a patient
Discharge Summary
comprehensive outline of patient's entire hostpital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patients response, final diagnosis, and follow-up plans
Informed Consent
document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure
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
Nurse's Notes
record of patient's care throughout the day; includes vital signs, treatment specifics, patient's response to treatment, and patient's condition
Anesthesiologist's Report
relates detailes regarding substances (such as medications and fluids) given to patient, patient's response to anesthesia, and vital signs during surgery
Operative Report
report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical procedure itsel, and how patient tolerated procedure
Pathologist's Report
report given by pathologist who studies tissue removed from patient (e.g., bone marrow, blood, or tissue biopsy)
Ancillary Reports
reports from various treatments and therapies patient has received, such as rehabilitation, social services, or respiratory therapy
Consultation Reports
reports given by specialists whom physician has asked to evaluate patient
Diagnostic Reports
results of diagnostic tests performed on patient, principally from clinical lab (e.g., blood tests) and medical imaging (e.g., X-rays and ultrasound)
History and Physical
written or dictated by admitting physician; details patient's history, results of physician's examination, initial diagnoses, and physician's plan of treatment
