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Definition
| written or dictated by the admitting physician; details the patient's history, results of the physician's examination, initial diagnoses, and physician's plan of treatment |
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| complete list of the care, medications, tests, and treatments the physician orders for the patient |
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| record of the patient's care throughout the day; includes vital signs, treatment specifics, patient's response to treatment, and patient's condition |
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| PHYSICIAN'S PROGRESS NOTES |
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Definition
| physician's daily record of the patient's condition, results of the physician' examinations, summary of test results, updated assessment and diagnoses, and further plans for the patient's care |
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| reports given by specialists whom the physician has asked to evaluate the patient |
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| reports from various treatments and therapies the patient has received, such as rehabilitation, social services, or respiratory therapy |
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| results of diagnostic tests performed on the patient, principally from the clinial lab (for example, blood tests) and medical imaging (for example, X-rays and ultrasound) |
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| document voluntarily signed by the patient or a responsible party that clearly describes the purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure |
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| report from the surgeon detailing an operation; includes a pre- and postoperative diagnosis specific details of the surgical procedure itself, and how the patient tolerated the procedure |
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| ANESTHESIOLOGIST'S REPORT |
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Definition
| relates the details regarding the substances (such as medications and fluids) given to a patient, the patient's response to anesthesia, and vital signs during surgery |
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| report given by a pathologist who studies tissue removed from the patient (for example, bone marrow, blood, or tissue biopsy) |
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Definition
| comprehensive outline of the 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 |
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