Elements of medical record

• Discharge Summary


  Comprehensive outline of patient's entire hospital stay, includes condtion at time of admission, admitting diagnosis, rest results, treatments and patient's response, final diagnosis, and follow-up plans
• pathologists report


  Report given by pathologist who studies tissue removed from patient (e g, bone marrows blood, or tissue biopsy)
• Anesthesiologist report


  Relates details regarding substances (such as medications and fluids)given to patient. patient's response to anesthesia, and vital signs during surgery
• Operative report


  Report from surgeon detailing an operation, includes pre and posteopentive dagnosis, specific details of surgical procedure itself, and how patient tolerated procedure
• Informed consent


  Documents voluntarily signed by patients or a responsible party that clearly describes purpose, method,procedure,benefits and risk of a diagnostic or treatment procedure.
• Diagnostic reports

  Results of diagnostic test performed on patient,principally from clinical lab for blood test and medical imaging ex. X-rays and ultrasound
• Ancillary reports


  Reports from various treatment and therapies patient has received, such as rehabilitation,social services or respiratory therapy
• Consultation reports


  Reports given by specialists whom physician had asked to evaluate patient
• Physician progress notes

  physicians daily record of patients condition,results of physicians examination,summary of test results,updated assessment and diagnoses, and further plans for patients care
• Nurse's notes


  Record of patients care throughout the day,includes vital signs, treatment specifics,patients response to treatment and patient's condition
• Physicians order

  Complete list of care,medications,test and treatment physician orders for patient
• History and physical

  written or dictated by admitting physician,details patient history,results of physician examination,initial diagnoses and physician plan of treatment