Common Elements of The Medical Record

• Written by admitting physician  

• Details patient's: 

  • History 

  • Exam results 

  • Initial diagnosis 

  • Physician's plan of treatment 

History & Physical  

• Ordered by the doctor 

• Complete list of:  

  • Care 

  • Medications 

  • Tests 

  • Treatments 

 

Physician's Orders 

• Records the patient's care throughout the day 

• Includes vital signs, treatment, specifics, patient's response to treatment, and the patient's condition. 

Nurse's Notes  

• Daily record of patient's condition 

• Results of a physical exam, summary of test results, updated assessment and diagnoses, and further plans for treatment. 

Physician's Progress Notes 

Given by a specialist when the physician asks for patient evaluation 

Consultation Reports 

• From various treatments and therapies 

• Such as rehabilitation, social services, respiratory therapy, or deictics 

Ancillary Reports  

• Results of all _______ tests performed on the patient. 

• From lab to medical imaging 

Diagnostic Reports 

• From surgeon detailing the operation 

• Includes pre and post-operative diagnosis 

• Specific details of the procedure and how the patient tolerated the procedure 

Operative Report 

• Relates details of drugs given to patient 

• Response to anesthesia  

• Vital signs during surgery 

Anesthesiologist's Report

Report given by the pathologist who studies tissue removed from patient 

Pathologist's report 

• Document voluntarily signed by the patient or responsible party 

• Clearly describes purpose, methods, procedures, benefits, and risks of procedures. 

Informed Consent  

• Outline of patient's entire hospital stay 

• Includes condition at admission, admitting diagnosis, test results, treatments, and patient's response, final diagnosis, and follow-up plans. 

Discharge Summary 

Provides Services to diagnose and treat diseases for a short period of time 

Acute Care or General Hospitals 

• Provides care for a specific type of disease 

• Example: psychiatric hospital  

Specialty Care Hospitals  

• Provides long-term care for patients who need extra time to recover before going home 

• For persons who cannot care for themselves 

Nursing Homes or Long-Term Care Facilities 

• For patients who do not need overnight care 

• Simple surgeries, therapy, or diagnostic testing 

Abulatory Care Centers, Surgical Centers, or Outpatient Clinics 

Individual or group of doctors providing diagnostic and treatment services in an office setting 

Physician's Offices 

• Group of primary care physicians, specialists, and other health care professionals 

• Provides wide range of services in a pre-paid system 

Health Maintenance Organization (HMO)  

Agencies that provide nursing, therapy, personal care, or housekeeping services in patient's home. 

Home Health Care 

• Provides physical and occupational therapy 

• Inpatient and outpatient 

Rehabilitation Centers 

Organized group of health workers that provide supportive treatment to terminally ill patients & their families 

Hospices