Components of a Medical Record Updated 2025 with complete solution
5 views 0 purchase
Course
Components of a Medical Record
Institution
Components Of A Medical Record
Physician's progress notes - Documentation given by the physician regarding the patient's
condition, results of the physician's examination, summary of test results, plan of treatment, and
updating of data as appropriate.
Operative Report - Documentation from the surgeon detailing the operation,...
Components of a Medical Record
Physician's progress notes - Documentation given by the physician regarding the patient's
condition, results of the physician's examination, summary of test results, plan of treatment, and
updating of data as appropriate.
Operative Report - Documentation from the surgeon detailing the operation, including the
preoperative and postoperative diagnosis, specific details of the surgical procedure, how well the patient
tolerated the procedure, and any complications that occurred
Medical History (Hx) - Document describing past and current history of all medical conditions
experienced by the patient
Physical Examination (PE) - Record that includes a current head-to-toe assessment for the
patient's physical condition
Consent form - Signed document by the patient or legal guardian giving permission for treatment
Informed Consent Form - Signed document by the patient or legal guardian that explains the
purpose, risks, and benefits of a procedure and serves as proof that the patient was properly informed
before undergoing a procedure.
Physician's Orders - Record of the prescribed care, medications, tests, and treatments for a given
patient
Nurse's Notes - Record of the patient's care that includes vital signs, particularly temperature (T),
Pulse (P), Respiration (R), and blood pressure (BP). The procedures, and patient's responses to such care.
Consultation Reports - Documentation given by specialists whom the physician has asked to
evaluate the patient
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller ACADEMICMATERIALS. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $7.99. You're not tied to anything after your purchase.
