worksheet 1F
diagnostic reports
results of diagnostic tests performed on the patient principally from the clinical lab and medical imaging
history and physical
written or dictated by the admitting physician
physicians orders
complete list of the care, medications, tests, and treatment the physician orders for the patient
discharge summary
comprehensive outline of the patients entire hospital stay
physicians progress notes
physician's daily record of the pts. condition, results of the physician's daily record of the examinations, summary of test results, updated assessments and diagnosis and further plans
nurses notes
record of the patients care throughout the day
anesthesiologist's report
relates the details regarding the substances given to a patient, patients responses, vital signs during surgery
operative report
report from the surgeon detailing on the operation
ancillary reports
reports from various treatments and therapies the patients has received
pathologist's report
reports given by a pathologist who studies tissue removed from the patient
consultation reports
reports given by specialists who the physician has asked to evaluate the pt.
informed consent
document voluntarily signed by the patient or a responsible party that clearly describes the purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure