Common Elements Of A Medical Chart

Front 1

History and Physical

Back 1

Written or dictated by the admitting physician; details about patients history, resultsof the physicians examination, initial diagnoses, and physicians plan of treatment

Front 2

Physician's Orders

Back 2

Complete list of the care, medications, tests, treatments the physician orders the patient

Front 3

Nurse's Notes

Back 3

Records of the patients care throughout the day; includes vital sign,treatment specifics, patients response to treatment, and their conditions.

Front 4

Physician's Progress Notes

Back 4

physicians daily records of the patients condition, result of examination, summary of tets results, updated assessments and diagnoses, and further plans for the patients care.

Front 5

Consultation Reports

Back 5

reports given by specialists whom the physicianhas asked to evaluate their patient

Front 6

Ancillary Reports

Back 6

reports from various treatments and therapies the patient has recieved.

Front 7

Diagnostic Reports

Back 7

results of diagnostic tests performed and medical imaging

Front 8

Informed Consent

Back 8

document voluntarily signed by the patient

Front 9

Operative report

Back 9

report from surgeon detailing an operation including specific details

Front 10

Anesthesiologist's Report

Back 10

relates the details regarding substances given to the patient, their response and vital signs during the surgery

Front 11

Pathologist's Report

Back 11

report given by pathologist wjo studies the tissue removed by the patient

Front 12

Discharge Summary

Back 12

comprehensive oultine of the patients hospital stay.