medical record

• Medical Record is a chart that documents a patient's hospital stay and serves as a permanent physical record of the patient.
• EMR stands for Electronic Medical Record, which is a software program that allows for entering of patient information via computer or tablet.
• History and Physical is a written or dictated by the admitting physician.
• Physician's Order is a complete list of physician orders for a patient.
• Nurse's Notes are a record of a patient's care throughout the day.
• Physician's Progress Notes are a physician's daily record of a patient's condition.
• Consultation Reports are reports given by specialists whom a physician has asked to evaluate a patient.
• Ancillary Reports are reports from various treatments and therapies a patient has received.
• Diagnostic Reports are results of diagnostic tests performed on a patient, including clinical lab and medical imaging.
• Informed Consent is a document voluntarily signed by a patient or a responsible party.
• Operative Report is a report from a surgeon detailing an operation, including pre and post operative diagnosis.
• Anesthesiologist's Report relates details regarding substances given to a patient.
• Pathologist's Report is a report given by a pathologist who studies tissue removed from a patient.
• Discharge Summary is a comprehensive outline of a patient's entire hospital stay.
• Acute Care or General Hospital provides services to diagnose and treat diseases for a short period of time.
• Specialty Care Hospital provides care for very specific types of diseases, such as psychiatric hospital.
• Nursing Homes or Long-Term Care Facilities provide long-term care for patients needing extra time to recover from illness or injury for persons who can no longer care for themselves.
• Ambulatory Care Centers, Surgical Centers, or Outpatient Clinics provide services not requiring overnight hospitalization.
• Physician's Offices provide diagnostic and treatment services in a private office setting.
• Health Maintenance Organization (HMO) provides a wide range of services by a group of primary care physicians in a prepaid system.
• Home Health Care provides nursing, therapy, personal care or housekeeping in a patient's own home.
• Rehabilitation Centers provide intensive physical and occupational therapy, including inpatient and outpatient treatment.
• Hospices provide supportive treatment to terminally ill patients and their families.
• Pharmacology is the study of the origin, characteristics and effect of drugs.
• Brand name or propriety name is a company's trademark.
• Chemical name describes the chemical formula or molecular structure of a particular drug.
• Generic name or nonpropriety name is recognized and accepted as the official name for a drug.
• Prescription drug can only be ordered by licensed healthcare practitioners such as physicians, dentists.
• Over the Counter Drug (OTC) does not require a prescription.
• Controlled drugs are classified if they have a potential for being addictive or can be abused.
• Schedule 1 drugs have the highest potential for addiction and abuse, are not accepted for medical use, and include heroin.
• Schedule 2 drugs have high potential for addiction and abuse, are accepted for medical use in the US, and include codeine, cocaine.
• Schedule 3 drugs have moderate to low potential for addiction and abuse, and include butabarbital, anabolic steroids.
• Schedule 4 - drugs with lower potential for addiction and abuse than schedule 3 drugs; example chloral hydrate, diazepam
• Schedule 5 - drugs with low potential for addiction and abuse; example low-strength codeine with other drugs to suppress coughing