EMR and healthcare settings

History and Physical

1: written and dictated by an admitting physician, details patiient history, results of physical exam, initial diagnosis, and plan for treatment

Physician's Orders

2: complete list of all care, medications, tests, and treatments physician orders for patients

Nurse's Notes

3: daily record of patient care throughout the day, includes vital signs, treatment specifics, patient's response to treatment, patient's condition

Physician's Progress Notes

4: physician's daily record of patient's condition, results of physician's exams, summary of test results, updated assessment and diagnosis and further plans with patient care

Consultation Reports

5: reports given by specialists whom physician has asked to evaluate patient

Ancillary Reports

6: reports from various treatments and therapies the patient received, including rehab, social services, or respiratory therapy

Diagnostic Reports

7: results of diagnosis tests performed on the patient, principally from the clinical lab (blood tests) and medical imaging (x-rays and ultrasound)

Informed Consent

8: document voluntarily signed by patient or responsible party that clearly describes purpose, methods, procedure, benefits, risks of a diagnosis, or therapeutic procedure

Operative Report

9: report given by surgeon detailing an operation includes pre and post operative diagnosis, specific details of surgical procedure itself, and how patient tolerated the procedure

Anesthesiologist's Report

10: related details regarding the substances (medications and fluids) given to the patient, how patient tolerated anesthesia, and vital signs during surgery

Pathologist's Report

11: report given by pathologist who studies tissue removed from the patient (bone marrow, blood, tissue biopsy)

Discharge Summary

12: comprehensive outline of patient's entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans

Acute Care or General Hospitals

provide services to diagnose (laboratory, diagnostic imaging) and treat (surgery, medications, therapy) diseases for a short period of time; in addition, they usually provide emergency and obstetrical care

Specialty Care Hospitals

provide treatment for very specific types of diseases

new york eye and ear infirmary

eyes ears throat head neck (specialty care hospital)

Home Health Care

provides nursing, therapy, personal care, or housekeeping services in patient's own home

Nursing Homes or Long-Term Care Facilities

provide long-term care for patients who need extra time to recover from an illness or injury before returning home, or for persons who can no longer care for themselves

Ambulatory Care Centers, Surgical Centers, or Outpatient Clinics

provide services not requiring overnight hospitalization, services range from simple surgeries to diagnostic testing or therapy

Hospices

provide supportive treatment to terminally ill patients and their families

Physicians' Offices

provide diagnostic and treatment services in a private office setting

Rehabilitation Centers

provide intensive physical and occupational therapy; includes inpatient and outpatient treatment

HMO

provides wide range of services by a group of primary-care physicians, specialists, and other healthcare professionals in a prepaid system