EMR medterm
EMR Overview
1. History and Physical
Written or dictated by the admitting physician
Includes:
Patient’s history
Results of physician’s examination
Initial diagnoses
Physician’s plan of treatment
2. Physician's Orders
Complete list of care, medications, tests, and treatments ordered for the patient
3. Nurse's Notes
Daily record of patient care
Vital signs
Treatment specifics
Patient’s response to treatment
Patient’s condition
4. Physician's Progress Notes
Daily record of:
Patient’s condition
Examination results
Test result summaries
Updated assessment and diagnosis
Further care plans
5. Consultation Reports
Reports from specialists evaluating the patient
6. Ancillary Reports
Reports from various treatments and therapies received by the patient
Rehabilitation, social services, respiratory therapy, etc.
7. Diagnostic Reports
Results of diagnostic tests (e.g., lab tests, imaging)
8. Informed Consent
Document signed by patient or responsible party
Describes:
Purpose
Methods
Procedures
Benefits
Risks
9. Operative Report
Details from the surgeon about the operation
Pre- and postoperative diagnosis
Specifics of the surgical procedure
Patient’s tolerance of the procedure
10. Anesthesiologist’s Report
Details on substances given to the patient during anesthesia
Patient’s response
Vital signs during surgery
11. Pathologist’s Report
Given by a pathologist analyzing tissue samples
Examples: Bone marrow, blood, tissue biopsy
12. Discharge Summary
Comprehensive outline of the hospital stay
Condition at admission
Admitting diagnosis
Test results and treatments
Final diagnosis and follow-up plan