| A | B |
|---|
| autopsy | a postdeath examination of the body, including disection ofthe internal organs, to determine cause of death |
| differential diagnosis | a tentative diagnosis, based on symptoms, made before any diagnostic tests are performed |
| principal diagnosis | the diagnosis that, after study, proves to be the reason for a patient's admission |
| respiratory and physical therapy | therapy to assist a patient with breathing and physical movement, respectively |
| face sheet | document that contains demographic information about the patient, including name, address, age,sex,telephobne number, attending physician, admitting diagnosis and admission and discharge dates. Face sheet may also contain the ICD or CPT codes and narrative descriptoions of final diagnosis and procedures |
| signature profile | form on which each caregiver(exce pt physician) records his/her initialsand full signature and title. |
| discharge summary | last document produced once patient has been discharged from hospital.Purpose: to provide future users of record with brief synopsis of patient's illness and treatment in hospital. |
| requirements of discharge summary | admitting diagnosis, final diagnosis, reason for admission, pertinent clinical findings and significant laboratory findings |
| hospital course | chronological review of the patient's treatment starting with the first day and ending with the patient's discharge or death |
| conditions on discharge | condition ofthe patient at time of discharge in relation to the condition of patient at admission |
| coding summary | a quick reference to the codes assigned and the resulting diagnosis-related group (DRG). Each DRG has a weight that determines hospital's reimbursement (from, for ex., Medicare |
| physician orders | preprinted forms on which physicians list orders for patient treatment |
| history and physical | the first report to be completed when a patient is admitted to the hospital. |
| purpose of history and physical | document the chief complaint of the patient, the differential diagnosis,and the initial proposed plan of treatment |
| the history portion documents these items | history of the present illness;history of past illness;family history;social history;review of symptoms |
| six major body systems to which the physician asks the patient to relate symptoms | (1)head, eyes, ears, nose, throat;(2)chest/lungs;(3)gastrointestinal;(4)genitourinary;(5)musculoskeletal;(6)neurologic) |
| specifications in a surgical consultation report | physician discussed the surgury and any alternatives, including risks and benefits. Should also state that the surgeons feels that the patient has given an informed consent to the surgury |
| frequency of progress notes | usually the physician writes one per day in acute care setting;if patient is extremely ill, physician may write more than one daily |
| critical care note (second visit note) | briefly documents why the physician saw the patient more than once in a day and what treatment was rendered |
| manual lab. reports | filed in chronological order by type of test.common typde of lab mount form contains 5-6 columns of adhesive |
| cancer-staging form | cancer is staged by surgeon or oncologist using a form which determines the stage of the cancer for treatment options and provides a way to compare cancer statistically |
| items on cancer-staging form: | size, lympth-node involvement, pathology, presence of didtant metastasis, and histopathology type and grade |
| BEGINNING items on pathology report | detailed description of the and other appearances; the specimen, (color, texture, size and other aspects of appearance |
| BODY of pathology report | contains pathologist's findings (both gross and microscopic),and may include photographs of the cell type |
| END of pathology report | pathologist's diagnosis based on examination of the specimen |
| radiology reports | reports of x-rays, nuclear scans, ultrasound, and other tests |
| cardiology reports | EKG results are usually typed on the actual EKG tracing and then in the record.Other types of reprts (such as echocardiograms) have their own formats in which results are recorded |
| PROCEDURE in procedure/operative reports | performing physician must document the preoperative and the postoperative diagnoses, and the operation performed. |
| OPERATIVE in the procedure/operative reports | a detailed report of the procedure beginning with the first incision and ending with the closure |
| preanesthesia note | (during surgury) anesthesiologist documents patient's vital signs, type and dosage of anesthetic,and results of anesthesia. Anesthesiologist is also required to document in a preanesthesia note that he talked to the patient about the risksand that patient consented to anesthesia notes required by JCAHCO , |
| postanesthesia note | w/i 24 hrs. following surgury, anesthesiologist documents results of examination of the patientincluding any (or lack of) complications with the anesthesia. Note must be dated and timed. Notes required by JCAHO |
| operating room clinical record | form used by the OR nurses to document pre and post diagnoses,planned and actual procedures performed,equipment used, and if correct,nurses names, date and time anesthesia started,operation start/end timesand anesthesia end time. |
| postanesthsia care unit (PACU) | documentation from recovery room:patient's vital signs, fluids and medications given, patient's progress until he/she is ready to return to regular nursing unit |
| preoperative preparation record | checklist of items that must be completed by nursing prior to surgury (H & P is complete;recording vital signs) |
| two ways to file related surgical documents | 1) separately by type in date order 2)filed together for a particular procedure |
| medication administration report | includes documentation of METHOD, SITE, DOSAGE and FREQUENCY of medication administration,time and date and nurse's initials;plus full signature of each( medication) administering nurse |
| Nursing DATABASE/discharge plan | completed upon ADMISSION: nurse records patient's understanding of reason for hospitalization,allergies, vital signs, medical history,patient's current medications, and presence of donor card. Also recorded: patient's personal , social and family histories,cultural and religeous preferences, primary language and barriers to learning |
| nursing database/DISCHARGE planning | completed upon ADMISSION: records any type of assisted living,whether patient needs glasses,crutches, etc.,anticipated need for assistance after discharge and to where patient will be discharged. |
| graphic daily care sheet | records vital signs, intake and output, weight, activities and appitite on daily basis.Allows caregivers to identify changes |
| assessment flow sheet | graphs body systems;easily identifies changes in patient's status |
| admission physical/risk for falls assessment | at admission, records patient's physical and also pain status by body system. Also conditions for risk of FALLING, such as mental status and age |
| nursing care plans | required by JCAHO, to ensure nursing care is focused towards patient's needs. Identifies focus of care, expected outcome, and plan for achieving outcome |
| teaching record | required by JCAHO,includes what was taught and to whom, and how the teacher knows that the patient has learned the material |
| nursing discharge status note/instruction sheet | 1)documents date and time of discharge;2)patient's condition at discharge and to where.2) Instructions include activity limitations, diet, signs and symptoms to watch for, medications and followup appointments |
| consents | signed in any invasive surgury:physician's name, surgeon's name,name of procedure in layperson's terms, date and time consent is signed, signiture of patient,signature and date of witness |
| Condition of Admission form | signed by patient at admission. allows hospital to treat patient and to perform minor stuff like taking blood. Form is also an agreement that patient will pay bill. Must be signed by patient;is witnessed by hospital employee |
| Emergency Dept. Record | contains demographic data about patient. Specifies how patient arrived, documents patient's chief complaint,vital signs, and any treatments given in ED,including medications. ED physician documents results of PE,tests ordered and impression of patient's problem. |
| discharge from ED | record must state condition of patient on discharge related to condition on admission;also disposition of patient (went home? transferred to another acute care facility, expired or admitted to hospital) |
| patient instructions | seperate document on which physician records instructions for followup treatment |
| paramedic report | includes condition of patient upon paramedic's arrival,what resuscitative measures were used and drugs given |
| record of death | contains patient's name, address, age,date and time of death,name of physician who pronounced patient dead, and cause of death |
| autopsy report | states pathologist's determination as to cause of death,and gives detailed description of all body systems examined, including weight and conditions of all major organs |
| transfer record | documents name and address of hospital transferring patient, patient's name, age and diagnosis, name and address of facility receiving patient, and reason for transfer.. Copy of completed form sent with patient to be put in receiving hospital's med. records |
| prenatal records | records of prenatal visits. Include miscarriges, previous deliveries, H & P,filed in same area where H & P would be found. |
