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HLHS 101 Ch2

Introduction to Health Records Types

Chief Complaint the main reason for the patient's visit
History of Present Illnesses the story of the patient's problem
Review of Systems description of individual body systems in order to discover any symptoms not directly related to the main problem
Past Medical History other significant past illnesses, like high blood pressure, asthma, or diabetes
Past Surgical History any of the patient's past surgeries
Family History any significant illnesses that run in the patient's family
Social History a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
Clinic Note documents a visit
Consult Note provides an expert opinion on a more challenging problem
Emergency Department Note documents an emergency department visit
Admission Summary documents the admission of a patient to the hospital
Discharge Summary describes when and why the patient was admitted; documents a longer stay
Operative Report documents a surgery in detail
Daily Hospital Note / Progress Note documents daily hospital visit
Radiology Report explains reason for image, how image was performed, what was seen on the image, radiologist's assessment; sometimes a recommendation
Pathology Report provides reason for test, what was seen on the test, and an assessment
Prescription provides directions for a medication
Created by: choover29