health documentation

Clinic Note

documents a patient visit in an office setting

consult note

provides an expert opinion on a more challenging problem

Emergency department note

documents an emergency department visit

Admission summary

documents the admission of a patient to the hospital

discharge summary

Comprehensive outline of patient's entire hospital stay

Operative report (OR)

Medical report that chronicles the details of a surgical procedure

daily hospital note/progress note

documents a patient's progress during a daily hospital visit

Radiology report

Explains reason for image, how image was performed, what was seen on image, radiologist's assessment

Pathology report

provides reasons for test, what was seen on the test, and an assessment

prescription

A written order from a doctor for a specific medicine