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Chief Complaint
Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words
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Operative Reports
- A formal document prepared by the principal surgeon to describe the surgical procedure(s) performed for the patient
- Should be written or dictated immediately after surgery and filed in the health record within 24 hours
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Preoperative H&P
- Except in emergency situations, every surgical patients chart must include a report of the complete history and physical conducted no more than 7 days before the surgery is to be performed
- Advance directives and organ donation forms must also be in chart
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APGAR
- Infant rating system done at 1 and 5 minutes after birth
- Score up to 10 (higher # better)
- Includes: Heart rate, Muscle tone, Respirations, Reflex, Color
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Prenatal Record
- Begins in the office or clinic when seen for first time for pregnancy
- Copy or abstract of prenatal information should be available at the birthing site by the 36th week of pregnancy
- Comprehensive history and physical exam includes many items
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Prenatal Record Ex.
- menstrual history
- reproductive history
- risk assessment
- health status
- reason for visit
- tobacco and/or alcohol usage
- dietary assessment
- history of abuse or neglect
- sexual practice
- physical fitness status
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Diagnosis at time of admission
What is happening when arrived at hospital.
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Consultation Reports
- Documents the clinical opinion of a physician other than the primary or attending physician
- Requested by primary or attending normally documented in physician orders or progress notes
- Based on consulting physician’s exam of the patient and a review of the patient health record
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Path Reports
- Analysis of all tissue and foreign objects removed surgically from a patient
- Normally dictated with an electronic signature from the Pathologist
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Path Reports Incl.
- Patient name, and MR#
- Date of Exam
- Description of tissue examined
- Diagnosis (both clinical and final)
- Findings-macroscopic (with own eye) and microscopic
- Name, credentials, and signature of pathologist
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Postpartum
- Information about the condition of the mother after the delivery process
- Example
- the condition of the breasts
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Physician Orders
- Instructions the physician gives to other healthcare professionals who actually perform diagnostic tests and treatments, administer medications, and provide specific services to the patients
- Orders must be legible dated and signed by physician
- Moving towards Computerized Physician Order Entry (CPOE) with the EHR
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Source-Oriented
- Documents are grouped together based on point of origin (according to patient care department)
- Reports in each section may be in chronological or reverse chronological order
- Example: Labs with Labs, Radiology with Radiology
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Source Oriented Advantages
- Very organized for each department to locate section for documentation
- Easy for adding loose papers
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Source Oriented Disadvantages
- Cannot determine all the patient’s problems and treatment quickly
- Must look in each area of the chart which is timely
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Problem-Oriented
- Itemized list of patient’s past and present social, psychological, and medical problems
- Each problem is indexed with unique number (problem list)
- Three sections: Database, Initial care plan, Progress notes
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Integrated Medical Record
Documentation from various sources is intermingled and follows strict chronological order
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Integrated Medical Record Adv.
Easy to follow the course of the patient’s diagnosis and treatment
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Integrated Medical Record Disadv.
Difficult to compare similar information
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SOAP
- Subjective
- Objective
- Assessment
- Plan
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Types of Progress Notes
- Admission Note
- Daily Notes
- Integrated Progress Notes
- Nursing Notes
- Discharge Note
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Recovery Room Report
A type of health record documentation used by nurses to document the patient’s reaction to anesthesia and condition after surgery; also called recovery room record
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Clinical Data
Documents medical condition, diagnoses, procedures, and treatment
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Clinical Data Ex.
- History and Phys.
- Diagnostic and therapeutic orders and results
- Progress Notes (clinical observations)
- Consultation Reports
- Nursing Notes
- Discharge Summary with discharge Instructions
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Administrative Data
- Demographic and financial information
- Consents and authorization
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Administrative Data Ex.
- Demographics and Financial Information
- Consents
- Authorizations (ROI)
- Advance Directives
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Authenticated
Validate/Confirm
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