The Medical Record documents the details of the patient’s hospital stay. Each healthcare professional who has contact with a patient is required to to complete an appropriate report and add it to the patient’s record. This produces a day-by-day timeline of the patient’s condition. The Medical Record is a legal document and is required to be filled out correctly and completely. Each page must have the patient’s proper identification information; such as, the patient’s name, age, gender, physician, admission date, and identification number.
A list of the most common documents found in a Medical Record and what they are is listed below.
History and Physical: written or dictated by the admitting physician; details the patient’s history, results of the physician’s examination, initial diagnoses, and physician’s plan of treatment.
Physician’s Orders: a complete list of care, medications, tests, and treatments the physician orders for the patient.
Nurse’s Notes: record of the patient’s care throughout the day; includes vital signs, treatment specifics, patient’s response to treatment, and patient’s condition.
Physician’s Progress Note: daily record of the patient’s condition, results of examinations, summary of test results, updated assessment and diagnoses, and plans for patient’s care.
Consultation Reports: reports done by specialists requested by the physician to evaluate the patient.
Ancillary Reports: from various treatments and therapies the patient received.
Diagnostic Reports: results of tests performed on patient from the lab (blood-work) and medical imaging (x-ray, ultrasound, etc.)
Informed Consent: a document that is signed voluntarily by the patient informing the patient the purpose, methods, procedures, benefits, and risks of the treatment procedure.
Operative Report: a report from the surgeon detailing an operation.
Anesthesiologist Report: detail regarding the substances given to the patient, the patient’s response, and vital signs during surgery.
Pathologist’s Report: report on tissue (bone marrow, blood, or tissue) removed from the body.
Discharge Summary: an outline of the patient’s entire hospital stay; including condition at time of admission, admitting diagnose, test results, treatments and patient’s response, final diagnosis, and follow-up plans.