Chapter 3

Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words

• 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

• 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

• 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

• 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

• 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

What is happening when arrived at hospital.

• 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

• Analysis of all tissue and foreign objects removed surgically from a patient
• Normally dictated with an electronic signature from the Pathologist

• 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

• Information about the condition of the mother after the delivery process
• Example
• the condition of the breasts

• 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

• 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

• Very organized for each department to locate section for documentation
• Easy for adding loose papers

• Cannot determine all the patient’s problems and treatment quickly
• Must look in each area of the chart which is timely

• 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

Documentation from various sources is intermingled and follows strict chronological order

Easy to follow the course of the patient’s diagnosis and treatment

Difficult to compare similar information

• Subjective
• Objective
• Assessment 
• Plan 

• Admission Note
• Daily Notes
• Integrated Progress Notes
• Nursing Notes
• Discharge Note

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

Documents medical condition, diagnoses, procedures, and treatment

• History and Phys.
• Diagnostic and therapeutic orders and results
• Progress Notes (clinical observations)
• Consultation Reports
• Nursing Notes
• Discharge Summary with discharge Instructions

• Demographic and financial information
• Consents and authorization

• Demographics and Financial Information
• Consents
• Authorizations (ROI)
• Advance Directives

Validate/Confirm