Define each document found in a medical record in the space provided.

Question

1. History and Physical


2. Physician’s Orders


3. Nurse’s Notes


4. Physician’s Progress Notes

5. Consultation Reports


6. Ancillary Reports


7. Diagnostic Reports


8. Informed Consent


9. Operative Report


10. Anesthesiologist’s Report


11. Pathologist’s Report


12. Discharge Summary

Answer 1

1. History and Physical—Written or dictated by admitting physician; details patient’s history, results of physician’s examination, initial diagnoses, and physician’s plan of treatment.

2. Physician’s Orders—Complete list of care, medications, tests, and treatments physician
orders for patient.

3. Nurse’s Notes—Record of patient’s care throughout day; includes vital signs, treatment
specifics, patient’s response to treatment, and patient’s condition.

4. Physician’s Progress Notes—Physician’s daily record of patient’s condition, results of
physician’s examinations, summary of test results, updated assessment and diagnoses, and further plans for patient’s care.

5. Consultation Reports—Report given by specialist whom physician has asked to evaluate patient.

6. Ancillary Reports—Reports from various treatments and therapies patient has received,
such as rehabilitation, social services, respiratory therapy, or dietician

7. Diagnostic Reports—Results of all diagnostic tests performed on patient, principally from lab and medical imaging (e.g., X-rays and ultrasound)

8. Informed Consent—Document voluntarily signed by patient/responsible party that clearly describes purpose, methods, procedures, benefits, and risks of diagnostic or treatment procedure.

9. Operative Report—Report from surgeon detailing operation; includes pre- and post-
operative diagnosis, specific details of surgical procedure itself, and how patient tolerated
procedure

10. Anesthesiologist’s Report—Relates details regarding drugs given to patient, patient’s
response to anesthesia, and vital signs during surgery

11. Pathologist’s Report—Report given by pathologist who studies tissue removed from patient. (e.g., bone marrow, blood, or tissue biopsy)

12. Discharge Summary—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