Medical records

History and physical

- Written by the admitting physician.

- Details the patient's:

1. History

2. Exam results

3. Initial diagnosis

4. Plan of treatment

Physician's orders

- Ordered by the doctor.

- Provides a complete list of:

1. Care

2. Medications

3. Tests

4. Treatments

Nurse's notes

- Completed by the nursing staff to record the patient's care throughout the day.

- Includes:

1. Vital signs

2. Treatment specifics

3. Patient's response to treatment

4. Patient's condition

Physician's progress notes

- The physician's daily record of the patient's condition.

- Generally include:

1. Results of the physical exam

2. Summary of test results

3. Updated assessment and diagnoses

4. Further plans for treatment

Consultation reports

- Given by a specialist when the physician asks for patient evaluation.

Ancillary reports

- From various treatments and therapies.

- May include rehabilitation, social services, respiratory therapy, or dietetics.

Diagnostic reports

- Include the results of all diagnostic tests performed on the patient.

- They are often written by the lab or the medical imaging department.

Informed consent

- A document voluntarily signed by the patient or responsible party.

- It clearly describes the purpose, methods, procedures, benefits, and risks of procedures.

Operative report

- From a surgeon detailing an operation.

- Includes:

1. Pre- and post-operative diagnoses

2. Specific details of the procedure

3. How the patient tolerated the procedure

Anesthesiologist's report

- Provides details of any drugs given to patient during surgery.

- Includes patient response to anesthesia and vital signs during surgery.

Pathologist's report

- A report given by a pathologist who studies tissue removed from the patient.

Discharge summary

- Outlines the patient's entire hospital stay.

- Includes:

1. Condition at admission

2. Admitting diagnosis

3. Test results or treatments

4. Patient's response

5. Final diagnosis and follow-up plans

Abbreviations

- Rx: The drug prescribed

- mg: Milligram, a unit of measure

- Sig: Instructions for the label

- Disp: Amount to dispense, number of refills