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12 Cards in this Set

  • Front
  • Back
History and Physical
Written or dictated by the admitting physician: details the patient's history.
Physician's Orders
Complete list of the care, meds, tests, and treatments the physician orders for the pt.
Nurse's Notes
Record of the pt's care throughout the day; includes vital signs, treatment specifics, and pt's conditions.
Physician's Progress Notes
Physician's daily record of the pt's condition: results of exams, summary of tests, and further plans for pt's care.
Consultation Reports
Reports given by specialists whom the physician has asked to evaluate the pt.
Ancillary Reports
Reports from various treatments and therapies the pt has received.
Diagnostic Reports
Results of diagnostic tests performed on the pt, principally from the clinical lab.
Informed Consent
Document voluntarily signed by the pt or responsible party that clearly describes the purpose, methods, and risk of procedure.
Operative Report
Report from the surgeon detailing an operation. Includes pre- and post-op diagnosis.
Anesthesiologist's Report
Relates the details regarding the substances given to the pt.
Pathologist's Report
Report given by a pathologist who studies tissue removed from the pt.
Discharge Summary
Comprehensive outline of the pt's entire hospital stay. Includes condition at time of admission, admitting diagnosis, test results, treatments and pt's response, final diagnosis, and follow-up plans.