medical terminology- chapter 1 (medical records)
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