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Chapter 6

Andressograph machine
Admission note
Admission/discharge record
Admitting disagnosis
Advance directive
Advance directive notification form
AMA- Against medical advice
Ambulance report
Ambulatory record
Ancillary reports
Ancillary service visit Anesthesia record
Antepartum record
Anto-dumping legislation
APGAR score
Attestation statement
Automatic stop order
Autopsy report
Bedside terminal system
Birth certificate
Birth history
Case management note
Certificate of birth
Certificate of death
CC- Chief complaint
Clinical data
Clinical resume
Conditions of admission
Consent to admission
Consultation report
Death certificate
Dietary progress note
Discharge order
Discharfe note
Discharge summary
Doctors orders
DRG creep
Durable power of attorney
Emergency record
Encounter form
Face sheet
Facility identification
Family history
Fee slip
Final diagnosis
First-listed diagnosis
Follow up progress note
Forms committee
Graphic sheet
Health care proxy
HPI- History of present illnesses
Informed consent
Integrated progress notes
Interval history
Labor and delivery record
Licensed practitioner
Maximizing codes
MAR_ Medication administration record
Necropsy report
Neonatal record
Newborn Id
Newborn physical examination
Newborn progress notes
Non-licensed practioner
Nurses notes
Nursing care plan
Nursing discharge summary
Nursing documentation
Obstetrical record
Occasion of service
Operative record
Outpatient visit
Past history
Pathology report
Patient ID
Patient record documentation committee
Patient property form
Physical examination
Physician office record
Physiciann orders
PACU- Postanesthesia evaluation unit
Postanehesia evaluation note
Postmortem report
Postoperative note
Postpartum record
Preanesthesia evaluation note
Prenatal record
Preoperative note
Principal disgnosis
Principal procedure
Progress notes
RAV- Read and verify
Recovery room record
Rehabilitation therapy progress note
Respiratory therapy progress note
ROS- Review of systems
Routine order
Secondary disgnoses
Secondary procedures
Short stay
Short stay record
Social history
Standing order
Stop order
Telephone order call back policy
Tissue report
Transfer order
UACDS- Uniform ambulatory Care data set
UHDDS- uniform hospital discharge data
Verbal order
Written order
Created by: s.fitzpatrick410
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