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
