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12 Cards in this Set
- Front
- Back
History and Physical
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Written or dictated by the admitting physician; details about patients history, resultsof the physicians examination, initial diagnoses, and physicians plan of treatment
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Physician's Orders
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Complete list of the care, medications, tests, treatments the physician orders the patient
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Nurse's Notes
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Records of the patients care throughout the day; includes vital sign,treatment specifics, patients response to treatment, and their conditions.
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Physician's Progress Notes
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physicians daily records of the patients condition, result of examination, summary of tets results, updated assessments and diagnoses, and further plans for the patients care.
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Consultation Reports
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reports given by specialists whom the physicianhas asked to evaluate their patient
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Ancillary Reports
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reports from various treatments and therapies the patient has recieved.
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Diagnostic Reports
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results of diagnostic tests performed and medical imaging
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Informed Consent
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document voluntarily signed by the patient
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Operative report
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report from surgeon detailing an operation including specific details
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Anesthesiologist's Report
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relates the details regarding substances given to the patient, their response and vital signs during the surgery
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Pathologist's Report
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report given by pathologist wjo studies the tissue removed by the patient
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Discharge Summary
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comprehensive oultine of the patients hospital stay.
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