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17 Cards in this Set
- Front
- Back
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medical records should |
be well organized, have proper terms |
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history and physical |
detailed information about patient |
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physicians notes |
early diagnosis and game-plan of treatment |
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physicians orders |
detailed list of orders, medications, tests, treatments |
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nurses notes |
idk |
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physician progress notes |
assessments and updates |
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consultation report |
notes from being referred to a specialist |
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ancillary report |
from the therapy or rehab |
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diagnostic reports |
tests performed or imaging done |
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advanced directive |
will, game-plan |
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informed consent |
voluntary document signed by patient, includes procedure details, treatment, benefits |
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operative report |
details of procedure, done by surgeon, pre/post, details, any complications, how patient tolerated procedure |
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detailed anesthesiology report |
medication used, tolerance and complications |
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pathologist report |
detailed report of what is happening to patients problem (from testing) |
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release report |
details, comprehensive report of what happened |
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SOAPS |
subjective data, objective data, assessment and plan |
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SNOMED |
"systematized nomenclature" systematized computerized collection of medical terms in medicine, gives codes that give cover many different medical terms |
