Medical Terminology Ch. 1: Types of Reports/Healthcare Settings
Physician's Progress Notes
Physician's daily record of patient's condition, results of physical examinations, summary of test results, updated assessment and diagnoses, and further plans for patient's care
Health Maintenance Organization
Provides wide range of services by a group of primary-care physicians and specialists in a prepaid system
Anesthesiologist's Report
Relates details regarding substances given to patient, patient's response to anesthesia, and vital signs during surgery
Operative Report
Report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical procedure itself, and how patient tolerated procedure
Pathologist's Report
Report given by pathologist who studies tissue removed from patient
Physician's Orders
Complete list of care, medications, tests, and treatments physician orders for patient
Discharge Summary
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
Informed Consent
Document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure
History and Physical
Written or dictated by admitting physician; details patient's history, results of physician's examination, initial diagnoses and physician's plan of treatment
Specialty Care Hospitals
Provide care for very specific types of diseases
Physicians' Offices
Provide diagnostic and treatment services in a private office setting
Rehabilitation Centers
Provide intensive physical and occupational therapy
Nursing Homes or Long-Term Care Facilities
Provide long-term care for patients needing extra recovery time, or for persons who can no longer care for themselves
Ambulatory Care Centers, Surgical Centers, or Outpatient Clinics
Provide services not requiring overnight hospitalization
Acute Care or General Hospitals
Provide services to diagnose and treat diseases for a short period of time; in addition, they usually provide emergency and obstetrical care
Hospices
Provide supportive treatment to terminally ill patients and their families
Home Health Care
Provides nursing, therapy, personal care or housekeeping services in patient's own home
Nurse's Notes
Record of patients care throughout the day; includes vital signs, treatment specifics, patient's response to treatment and patient's condition
Ancillary Reports
Reports from various treatments and therapies patient has received such as rehabilitation, social services or respiratory therapy
Consultation Reports
Reports given by specialists whom physician has asked to evaluate patient
Diagnostic Reports
Results of diagnostic tests performed on patient, principally from clinical lab and medical imaging