Elements of the Medical Record

Physician's Progress Notes

- Daily record of patient's condition - Results of physical exam, summary of test results, updated assessment and diagnosis, and further plans for treatment

Informed Consent

- Document voluntarily signed by the patient or responsible party - Clearly describes purpose, methods, procedures, benefits, and risks of procedures

Operative Report

- From surgeon detailing the operation - Includes: pre- and post-operative diagnosis - Specific details of the procedure and how the patient tolerated the procedure

Ancillary Reports

- From various treatments and therapies - Such as rehabilitation, social services, respiratory therapy, or dietetics

Consultation Reports

- Given by a specialist when the physician asks for patient evaluation

Physician's Orders

- Ordered by the doctor - Complete list of: care, medications, tests, and treatments

Discharge Summary

- Outline of patient's entire hospital stay - Includes: condition at admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans

Nurse's Notes

- Records the patient's care throughout the day - Includes vital signs, treatment specifics, patient's response to treatment, and patient's condition

Anesthesiologist's Report

- Relates details of drugs given to patient - Response to anesthesia - Vital signs during surgery

Pathologist's Report

- Report given by pathologist who studies tissue removed from patient

Diagnostic Report

- Results of all diagnostic tests performed on the patient - From lab to medical imaging

History and Physical

- Written by admitting physician - Details patient's: history, exam results, initial diagnosis, and Physician's plan of treatment

Medical Record

Documents details of hospital stay: - Patient's day-to-day condition - When and what services were provided - Response to treatment