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9 Cards in this Set
- Front
- Back
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Patient Data Sheet |
- insurance information - admitting physician -family physician -patient stats: age, occupation, address, family, etc -admitting diagnosis |
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physician's orders |
- orders for medication, tests, consultations, nursing orders and PT referrals
- 1st place to look in pt. med rec |
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admissions note |
- emergency room (admitting) physicians findings -patients medical and physical history - results of ER testing - physicians impressions (diagnosis) and plan |
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nursing/progress notes |
- also used by resident physician, social work, dietary, and special testing - denotes change and concerns with patient progress to specific treatment - physical therapy and all other rehab staff will document ongoing notes - 4th - to see if anything has changed |
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rehab notes |
- usually in rehab facilities - holds notes from PT, OT, Speech - 3rd |
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Consultations |
- reports and findings (evaluations) of requested consults from specialist
- could include: cardiology, oncology, neurology, ENT, PT, etc
- 2nd where initial eval for every other person go (PT Eval location) |
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Labs/ Special Test |
result f blood work, testing (CT, MRI, ECG, bone scans, Doppler studies, X-rays) |
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medication |
- documents medication, intervals, doages, and changes
- may be found in daybook or medication chart |
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vital signs |
- denotes blood pressure, heart rate, pulse, and temp
-may be found in daybook or bedside clipboard
- always check yourself |
