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12 Cards in this Set
- Front
- Back
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written or dictated by the admitting physician: details patients history, results of the physicians examination, initial diaagnoses, and physicians plan of treatment
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History and Physical
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complete lilst of the care, medications, tests, and treatments the physician orders for the patient
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Physicians orders
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record of the patients care throughout the day: includes vital signs, treatment specifics, patients response to treatment and patients condition
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Nurse's Notes
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Physicians daily record of the patients condition, results of the physicians examination, summary of test results, updated assessment and diagnoses, and further plans for the patients care
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Physicians progress Notes
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reports given by specialists whom the physician has asked to evaluate the patient
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Consultation 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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Ancillary Reports
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results of diagnostictests performed on the patient, principally from the clinical lab (for example, blood tests) and medical imaginge (for example, X-rays and ultrasound)
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Diagnostic Reports
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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 a diagnostic or treatment procedure
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Informed Consent
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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 procedure
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Operative report
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relates the details regarding the substances (such as medications and fluids) given to a patient, the patients response to anesthesia, and vital signs during surgery
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Anesthesiologists Report
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report given by a pathologist who studies tissue removed from the patient (for example, bone marrow, blood, or tissue biopsy)
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Pathologists Report
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comprehensive outline of the patients entire hospital stay:includes condition at a time of admission, admitting diagnosis, test results, treatments and patients response, final diagnosis, and follow-up plans
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Discharge Summary
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