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12 Cards in this Set
- Front
- Back
History and Physical
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Written or dictated by the admitting physician: details the patient's history.
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Physician's Orders
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Complete list of the care, meds, tests, and treatments the physician orders for the pt.
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Nurse's Notes
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Record of the pt's care throughout the day; includes vital signs, treatment specifics, and pt's conditions.
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Physician's Progress Notes
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Physician's daily record of the pt's condition: results of exams, summary of tests, and further plans for pt's care.
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Consultation Reports
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Reports given by specialists whom the physician has asked to evaluate the pt.
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Ancillary Reports
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Reports from various treatments and therapies the pt has received.
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Diagnostic Reports
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Results of diagnostic tests performed on the pt, principally from the clinical lab.
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Informed Consent
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Document voluntarily signed by the pt or responsible party that clearly describes the purpose, methods, and risk of procedure.
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Operative Report
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Report from the surgeon detailing an operation. Includes pre- and post-op diagnosis.
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Anesthesiologist's Report
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Relates the details regarding the substances given to the pt.
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Pathologist's Report
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Report given by a pathologist who studies tissue removed from the pt.
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Discharge Summary
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Comprehensive outline of the pt's entire hospital stay. Includes condition at time of admission, admitting diagnosis, test results, treatments and pt's response, final diagnosis, and follow-up plans.
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