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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 patien's history, results of the physician's examination, inital diagnoses, and physician's plan of treatment
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Physician's Order
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complete list of the care, medicatons, test, and treatments the physician orders for the patient
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Nurse's Notes
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record of the patien's care throughout the day; includes vital signs, treatment specifics, patient's response treatment, and patient's condition
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Physician's Progress Notes
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Physician's daily record of the patient's condition, results of the physician's examinations, summary of 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 specialists whom the physician has asked to evaluate the patient
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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 preformed on the patient, principally from the clinical lab (for example, blood tests)and medical imaging (for example X-ray and ultrasound)
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Informed Consent
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Document voluntarily signed by the patient or a resonsible party that clearly describes the purpose, methods, procedures, benefits, and risks of 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 procedure
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Anesthesiologist's Report
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Relates the details regarding the substances (such as medications and fluids) given to a patient, the patient's response to anesthesia, and vital signs during surgery
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Pathologist's 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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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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