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Health Records

Different notes used in the medical setting

TermDefinition
Clinic Note How health care professionals document a visit in an office setting. May be handwritten, dictated, or electronic.
Consult Note A note from a visit to a specialist. Can be written as a letter.
Emergency Department Note Mix of completed diagnostic tests, patient assessments, and a plan from an ED visit.
Admission Summary Summary from medical professional detailing the assessment and plan upon admitting a patient
Discharge Summary Summary of admission details, details pertaining to a patients hospital stay, and the follow up. This note leads with diagnosis.
Operative Report Report from a surgeon that documents the surgery and the outcome. The report leads with diagnosis.
Daily Hospital Note/ Progress Note Health care professionals daily documentation of a patients stay.
Radiology Report Reason for ordering image, how image was performed, what was seen, and the assessment from the Radiologist
Pathology Report Reason for study, what was seen, and the assessment from the Pathologist.
Prescription Instructions written by a medical professional advising the use of medication or treament.
Created by: Olablanton