The Medical Record

Front 1

History and Physical

Back 1

written or dictated by admitting physician; details the patients history, results of the physician's examination, initial diagnoses, and physician's plan of treatment

Front 2

Physician's orders

Back 2

Complete list of the care, medications, tests, and treatments the physicans order for the patient.

Front 3

Nurse's Notes

Back 3

Record of the patient's care throughout the day; includes vital signs, treatment specifics, patients response to treatment, and patient's condition.

Front 4

Physician's Progress Notes

Back 4

Physicians daily record of the patient's condition, results of the physician's examinations, summary of the test results, updated assessment and diagnoses,, and further plans fo rthe patient's care.

Front 5

Consultation Reports

Back 5

Reports given by specialists whom the physician has asked to evaluate the patient

Front 6

Ancillary Reports

Back 6

Reports from various treatments and therapies the patient received, such as rehabilitation, social services, or respiratory therapy

Front 7

Diagnostic Reports

Back 7

Results of diagnostic tests preformed on the patient, principally from the clinical lab (for example,, blood tests) and medical imaging ( for example, x-rays and ultrasound).

Front 8

Informed Consent

Back 8

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.

Front 9

Operative Report

Back 9

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

Front 10

Anesthesiologist's Report

Back 10

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.

Front 11

Pathologist's Report

Back 11

Report given by a pathologist who studies tissue removed from the patient (for example, bone marow, blood, or tissue biopsy)

Front 12

Discharge Summary

Back 12

Comprehensive outline of the patient's entire hospital stay; includes condition at time of admission, admitting diagonosis, test results, treatments and patiets' response, final diagnosis, and follow-up plans.