Medical Terminology Hospital Records

Front 1

History and Physical form

Back 1

documentation of patient's recent medical history and results of physical exam required before hospital admit

Front 2

Consent form

Back 2

document signed by patient or legal guardian giving permission for medical or surgical care

Front 3

Informed consent

Back 3

consent of pt after being informed of risks and benefits of procedure and alternatives`

Front 4

Physician's orders

Back 4

record of all orders directed by attending physician

Front 5

Diagnostic tests/lab reports

Back 5

records of results of various tests and procedures used in eval

Front 6

Nurse's notes

Back 6

documentation of pt care by nursing staff

Front 7

Physician's progress notes

Back 7

physician's daily account of pt's response to treatment- test results, assessment, future treatment plans

Front 8

Ancillary reports

Back 8

miscellaneous records of procedures or therapies provided during pt's care

Front 9

Consultation report

Back 9

report filed by a specialist asked by attending to eval a difficult case or outpatient report

Front 10

Operative report

Back 10

surgeon's detailed account of operation and pt responses during procedure

Front 11

Pathology report

Back 11

report of findings of a pathologist after study of tissue

Front 12

Discharge summary, Clinical resume, Clinical summary, Discharge abstract

Back 12

four terms that describe an olutline summary of pt's hospital care- date of admit, diagnosis, treatment course, date of discharge