Patient Chart

• The age, race, name, address, social security number marital status, insurance

  Patient demographics
• a narrative or record of past events and circumtances that are or may be revelant to a patients current state of health

  Patients medical chart
• attending physician, date and time of admisson room number, admitting diagnoses e.g

  facts relative to admission
• the statement generally puts patient under the control of the hospital for its care

  Consent of treatment statement
• a requirement of medicare. it may be seperate or it may be incorporated as part of admission report.

  attestation statement
• what includes in the medical history

  chief complaint

  history of present illness

  patient medical history

  social history

  family history

  review of systems
• what are the physical examinations

  inspection

  palpation

  percussion

  auscultation
• these are the “marching orders” of the attending physician

  physician orders
• includes regular notes on the patient's status by the

  interdisciplinary care team.

  Progress notes
• document that contains the diagnosis determined by examining cells and tissues under a microscope.

  pathology report
• Used to document a baseline nursing history and assessment for the patient.

  Used to document accomplishment of tests, treatments, and nursing orders.

  Nurse notes
• Vital signs record includes:

  temperature

  pulse rate

  respiratory rate

  blood pressure
• report that serves as a legal record of

  the drugs administered to a patient at a facility by a

  health care professional.

  Medication and administration record
• • contains final instructions for the patient

  • Summation of all activities during the patient’s course of hospitalization

  Discharged summary
• To direct to a source for help or

  information

  Referral form
• To submit (a matter in dispute) to a medical specialist/s for arbitration, decision, or examination.

  referral form
• Surgical form includes

  pre-operating diagnosis

  procedures to be done

  findings

  details

  recommendation
• any measurable fluid that goes into the patients body.

  intake
• measurable fluid that comes from the body (urine, drainage, vomitus)


  Output
• Documented by the nurse on duty to properly identify the time of administration.

  Medication and treatment sheet
• notes from specialized diagnosticians or care

  providers.

  Consultations
• includes permissions signed by patient for procedures, tests, or access to chart.

  Consents
• comprehensive written summary of all regular

  medicines taken by a patient

  patient medication profile
• current. medication list of the patient

  Standing medication
• drugs for emergency purposes

  Stat medication
• current IV therapy of the patient

  intravenous medication