Ch 1 Introduction to Medical Terminology (The Medical Record)

Health Insurance Portability & Accountability Act of 1996

(HIPAA) set federal standards that provide patients with more protection of their medical records and health information, better access to their own records, and greater control over how their health information is used and to whom it is disclosed.

physician's orders

Complete list of the care, medications, tests, and treatments the physician orders for the patient

nurse's notes

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

medical record

chart documents the details of a patient's hospital stay -each healthcare professional who has contact with the patient in any capacity completes the appropriate report of that contact and adds it to the medical chart.

discharge summary

comprehensive outline of the 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.

informed consent

document voluntarily signed by the patient or a responsible party that clearly describes the purposes, methods, procedures, benefits, and risks of a diagnositc or treatment procedure

physician's progress notes

physician's daily record of the patient's condition, results or the physician's examinations, summary of test results, updated assessment and diagnoses, and further plans for the patient's care.

anesthesiologist's report

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

opertative report

report from the surgeon detailing an operation; includes a pre- and postoperative diagnosis, specific details of the surgical procedure itself, and how the patient tolerated the procedure

pathologist's report

report given by a pathologist who studies tissue removed from the patient (for ex, bone marrow, blood, or tissue biopsy)

ancillary reports

reports from various treatments and therapies the patient has received, such as rehabilitation, social services, or respiratory therapy

consultation reports

reports given by specialists whom the physician has asked to evaluate the patient

diagnostic reports

results of diagnostic tests performed on the patient, principally from the clinical lab (for ex, blood tests) and medical imaging (for ex, X-rays and ultrasound)

history and physical

written or dictated by the admitting physician; details the patient's history, results of the physician's examination, initial diagnoses, and physician's plan of treatment