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
