Components of
the Hospital Chart
Discharge
Summary
·
a complete summarization of a patients course while in
the hospital, prepared by the patients physician.
·
contains admitting problems and diagnosis, treatment and
medications, lab results and radiology studies, a summary of consultations,
discharge diagnosis, prognosis and a plan for treatment following diagnosis.
Admission Record
·
typed record noting the reason for admission
·
results of preliminary tasting, relevant history proposed
plan of treatment
Emergency Room
Record
·
there is an admission chart in the E.R.
History and
Physical
·
outlines the patients chief complaint as well as complete
medical history prior treatment and medications as well as family medical
history
Progress Records
·
daily handwritten notes of the attending physician
Physician Orders
·
orders for treatment written by the physician
·
include all tests and medications and procedures to be
performed
·
the nurse pulls the orders from the chart and renders the
medications
Consultations
·
examinations and consultations by various doctors
Pre-Op Note
·
record of patients history treatments
Operative Note
·
surgeons records and a detailed outline from start to
finish
Anesthesiology
·
a record of pre-anesthesia medical history, heart, pulse
rate, start and stop times, typed rendered dosages, vital signs, respiration,
oxygen, fluid rate, heart rate, airway, machine and ventilation
Medication
·
list of medications taken, dosage and times drugs are
given
Nurses Notes
·
chronological, clinical picture of nursing care rendered
beginning with patients admission
·
condition on arrival, previous instances, hospital stays,
prior medical problems, complaints and other info.
Graphic Charts
·
pulse, temperature, respiration, blood pressure, vital
signs, patients weight and fluid intake
Lab and
Pathology Reports
Tests
·
blood
·
urine
·
pregnancy
Radiology
Reports
X-ray
·
basic background info
·
name
·
address
·
history
Consent Forms
·
patients signs upon admission
No comments:
Post a Comment