Describe the parts of the Medical Record.

Question

What will be an ideal response?

Answer 1

• History and Physical—details the patient's history, results of the physician's examination, initial diagnoses, and physician's plan of treatment
• Physician's Orders—a complete list of the care, medications, tests, and treatments the physician orders for the patient
• Nurse's Notes—record of the patient's care throughout the day
• Physician's Progress Notes—the physician's daily record of the patient's condition, results of the physician's examinations, summary of test results, updated assessment and diagnoses, and further plans for the patient's care
• Consultation Report—the report given by a specialist whom the physician has asked to evaluate the patient
• Ancillary Reports—reports from various treatments and therapies the patient has received
• Diagnostic Reports—results of all diagnostic tests performed on the patient
• Informed Consent—a 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
• Operative Report—report from the surgeon detailing an operation
• Anesthesiologist's Report—relates the details regarding the drugs given to a patient, the patient's response to anesthesia, and vital signs during surgery
• Pathologist's Report—the report given by a pathologist who studies tissue removed from the patient
• Discharge Summary—a comprehensive outline of the patient's entire hospital stay