EMR medterm

History and Physical

Written or dictated by the admitting physician, includes patient's history, examination results, initial diagnoses, and the physician's plan of treatment.

Physician's Orders

A complete list of care, medications, tests, and treatments ordered for the patient.

Nurse's Notes

A daily record of patient care, including vital signs, treatment specifics, patient’s response to treatment, and patient’s condition.

Physician's Progress Notes

A daily record of the patient’s condition, examination results, test result summaries, updated assessment, diagnosis, and further care plans.

Consultation Reports

Reports from specialists evaluating the patient.

Ancillary Reports

Reports from various treatments and therapies received by the patient, including rehabilitation and social services.

Diagnostic Reports

Results of diagnostic tests such as lab tests and imaging.

Informed Consent

A document signed by the patient or responsible party that describes the purpose, methods, procedures, benefits, and risks.

Operative Report

Details from the surgeon about the operation, pre- and postoperative diagnosis, specifics of the surgical procedure, and the patient’s tolerance.

Anesthesiologist’s Report

Details on substances given to the patient during anesthesia, the patient's response, and vital signs during surgery.

Pathologist’s Report

Provided by a pathologist analyzing tissue samples, such as bone marrow, blood, and tissue biopsy.

Discharge Summary

A comprehensive outline of the hospital stay, including condition at admission, admitting diagnosis, test results, treatments, and final diagnosis with follow-up plan.