The flashcards below were created by user
lorenb2k
on FreezingBlue Flashcards.
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Admission record/facesheet
- Name of form
- Patinet age/DOB
- Attending physician
- Admitting/Principal diagnosis
- Physician name and signature, w/Date/Time
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Discharge summary
- Name of form
- Admitting Dx
- Discharge Dx
- Inpatient Hx
- Admitting/Principal diagnosis
- Physician name and signature, w/date/time
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Informed consent form
- Name of form
- Patient name
- Admission date
- Legal representative
- Witness signature
- Attending physician name and signature, w/date/time
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History and Physical form
- Chief complaint
- Admitting/Principal Dx
- Past medical Hx
- Personal Hx
- Family Hx
- Record of physician's findings
- Attending physician name and signature, w/date/time
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Dr. progress notes
- Admitting note
- Date, time, entry for each day
- Attending physician name and signature, w/date/time
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Doctor's orders
- State type of order: Written, verbal, standing (patinet specific), or automatic (narcotics etc...)
- Attending physician name and signature, w/date/time
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Radiology Report
- Title of form
- Pt name and info
- Reason for x-rays
- Time of dosage
- Findings
- Radiologist name and signature, w/date/time
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Laboratory report
- Type of labs
- Date/time ordered (*see Drs order)
- Results which may indicate low/high findings
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Graphic record (TPR report) temperture, respiration and pressure)
Daily results of fluid in/out take
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Medication Record
- List allergies to medication
- Medications (dosage/route/time)
- Initials and siganture of med assistants
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PRN mean:
- "Pro re nata"
- As needed
- or
- As circumstances arises
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Nurse's notes
- EACH NOTE:
- Daily entry (frequently)
- List of treatments and notes w/date/time
- also Discharge note
- RN name and signature, w/date/time
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Nurse's Discharge summary form
- Patient name and details
- Vitals
- Medications
- Instructions to family
- D/C time
- Comments
- RN name and signature, w/date/time
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Patient Property Record form
- 1. Statement to store personal items safely
- 2. Statement to store patient money/valuables safely
- 3. Statement to dispose, store or administer of patient medications as recommend by personal physician
- Patient signature, date/time on each section
- Assisting staff name and signature, w/date/time
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