Elements Of The Medical Record

Front 1

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

Back 1

History and Physical

Front 2

Complete list of care, medications, tests, and treatments physicians order for patient.

Back 2

Physician's Orders

Front 3

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

Back 3

Physician's Progress Notes

Front 4

Reports given by specialists whom physician has asked to evaluate patient

Back 4

Consultation Reports

Front 5

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

Back 5

Ancillary Reports

Front 6

Results of diagnostic test performed on patient, principally from clinical lab (e.g blood test) and medical imaging (e.g X-Ray)

Back 6

Diagnostic Reports

Front 7

Document voluntarily signed by patient or responsible party that clearly describes purpose, methods, procedures, benefits and risks of diagnostic or treatment for procedure.

Back 7

Informed Consent

Front 8

Report from surgeon detailing an operation; including pre and post operative diagnostics, specific details of surgical procedure itself, and how patient tolerated procedure

Back 8

Operative Report

Front 9

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

Back 9

Anesthesiologist's Report

Front 10

Report given by a pathologist who studies tissue removed from a patient (e.g. bone marrow, blood, or tissue biopsy)

Back 10

Pathologist's Report

Front 11

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

Back 11

Discharge Summary