Med Term Medical Record

History and Physical

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

Anesthesiologist's Report

(10) Relates details regarding substances (such as medications and fluids) given to patient, patient's response to anesthesia, and vital signs during surgery

Pathologist's Report

(11) Report given by pathologist who studies tissue removed from patient (e.g., bone marrow, blood, or tissue biopsy)

Discharge Summary

(12) Comprehensive outline of patient's entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans

Physician's Orders

(2) Complete list of care, medications, tests, and treatments physician orders for patient

Nurse's Notes

(3) Record of patient care throughout the day; includes vital signs, treatment specifics, patient's response to treatment, and patient's condition

Physician's Progress Notes

(4) Physician's daily record of patient care, results of physician's examinations, summary of test results, updated assessments and diagnosis, and further plans for patient's care

Consultation Reports

(5) Reports given by specialists whom physician has asked to evaluate patient

Ancillary Reports

(6) Reports from various treatments and therapies patient has received, such as rehabilitation, social services, or respiratory therapy

Diagnostic Reports

(7) Results of diagnostic tests performed on patient, principally from clinical lab (e.g., blood tests) and medical imaging (e.g., X-rays and ultrasound)

Informed Consent

(8) Document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure

Operative Report

(9) Report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical procedure itself, and how patient tolerated procedure

What are the 12 parts of the medical record (in order)?

1. History and Physical 2. Physician's Orders 3. Nurse's Notes 4. Physician's Progress Notes 5. Consultation Reports 6. Ancillary Reports 7. Diagnostic Reports 8. Informed Consent 9. Operative Report 10. Anesthesiologist's Report 11. Pathologist's Report 12. Discharge Summary

Who has to add to the medical record?

Any healthcare professional that has contact with patient in any capacity has to complete an appropriate report of that contact

Why is it necessary for each healthcare institution to adopt a specific format for each document and its location in the medical record?

Each healthcare professional must be able to quickly and efficiently locate the information they need to provide proper care for their patient

What must each page of the medical record contain?

The patient ID information: name, age, gender, physician, admission date, ID number

Is a medical record a legal document?

Yes

A ____ _____ keeps the documents in the right place while the patient is in the hospital. After discharge, the _______ _______ __________ takes care of the documents.

unit clerk, medical records department