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10 Cards in this Set
- Front
- Back
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Documents a surgery in detail |
Operative Report |
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Provides reasons for test, what was seen on test, and an assessment |
Pathology Report |
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Provides directions for a medication |
Prescription |
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Documents daily hospital visit |
Daily Hospital note/progress note |
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Documents a visit |
Clinic Note |
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Provides an expert opinion on a more challenging problem |
Consult Note |
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Documents an emergency department visit |
Emergency department note |
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Documents the admission of a patient to the hospital |
Admission summary |
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Describes when and why the patient was admitted; documents on a longer stay |
Discharge summary |
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Explains reason for image, how image was performed, what was seen on image, radiologist's assessment; sometimes a recommendation |
Radiology Report |
