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12 Cards in this Set
- Front
- Back
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History and Physical
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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.
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Physician's orders
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Complete list of the care, medications, tests, and treatments the physician orders for the patient.
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Nurse's notes
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Record of the patient's care throughout the day; includes vital signs, treatment specifies, patient's response to treatment, and patient's condition.
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Physician's progress notes
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Physicians daily record of the patient's condition, results of the physician's examinations, summary of the test results, updated assessment and diagnoses, and further plans for the patient's care.
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Consultation reports
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reports given by specialist whom the physician has asked to evaluate the patinet
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Ancillary reports
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reports from various treatments and therapies the patient has received, such as rehabilitation, social services, or respiratory therapy
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Diagnostic reports
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results of diagnostic tests performed on the patient, principally from the clinical lab (for example, the blood) and medical imaging (for example x-rays and ultrasound)
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Informed Consent
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Document voluntarily signed by the patient or a responsible party that clearly describes the purpose, methods, procedures, benefits, and risks of the diagnostic or treatment procedure
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Operative report
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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 porcedure
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Anesthesiologist's report
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Relates the details regarding the substances (such as medications and fluids) given to the patient, the patient's response to anesthesia, and vital signs during surgery
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Pathologists Report
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report given by a pathologist who studies tissue removed from the patent (for example, bone marrow, blood, or tissue biopsy
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Discharge summary
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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
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