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25 Cards in this Set
- Front
- Back
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history and physical |
dr. writes history, exam, diagnoses, and tx |
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physician's orders |
complete list of care, meds, ,tests, and tx |
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nurse's notes |
record of care throughout the day, vitals, tx specifics, response, and condition |
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physician's progress notes |
record of condition, results of exam, tests, assessments, diagnoses, and plans |
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consultation reports |
report by another doctor asked to examine a patient |
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ancillary reports |
other department's notes and history |
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diagnostic reports |
results of tests from the lab and med. imagining (x-rays, ultrasound, MRI's, CT's) |
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informed consent |
document signed by patient or guardian; describes purpose, procedures, benefits, and risks |
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operative report |
surgeon's report about an operation with pre/post notes pertaining to the operation |
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anesthesiologist's report |
detailed report regarding drugs given, response, and vital signs during operation |
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pathologist's report |
dr.'s report who studied patient's tissue |
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discharge summary |
outline of entire stay, condition at intake, diagnoses, tx, test results, and follow up |
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acute care |
provides services to diagnoses and treat for short periods of time |
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general hospitals |
usually provide emergency and obstetrical care for short periods of time |
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specialty care hospitals |
provide tx and care for specific types of diseases |
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nursing homes |
provide care for people who can't for themselves |
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long-term facility care |
provide long term care for patient's recovery |
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ambulatory care |
provide services that don't require overnight stay |
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surgical centers |
provide simple surgeries that don't require long term stay |
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outpatient clinics |
doesn't require overnight stay for tx |
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physicians' office |
individual or groups of dr.'s in a private office setting |
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health maintenance organizations |
primary-care physicians and specialists that provide wide range of prepaid services |
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home health care |
nursing, therapy, personal care, or housekeeping services in a patient's home |
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rehabilitation centers |
provide intensive physical and occupational therapy w/ both inpatient and outpatient services |
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hospices |
organized group who provide supportive tx to dying patients and their families |
