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Chapter 2

Types of Health Records

TermDefinition
Clinic Note handwritten, dilatated, electronic circle or checkbox on a template *follows SOAP method*
Consult Note A note from a visit to a specialist, or consultant, typically to a primary care provider *typed letter- uses SOAP method*
Emergency Department Note must get a good family history 1. Any completed diagnostic tests 2.patient assessment 3. a plan for the patient over time -SOAP
Admission Summary patients must provide medical history and receive a physical exam 1. through notes on subjective/objective parts 2.the assessment- thoughts on a patient diagnosis, list of possible causes 3. The plan - further testing & patient care -SO/AP
Discharge Summary 1. when and why a patient was admitted 2. How patient felt when admitted 3.what happened during patient stay in hospital 4.what kind of follow up patient will have -ASOP
Operative Report 1.in detail the procedure that was performed 2.Events that transpired during surgery 3. Patients outcome, along, with discharge summary -ASOP
Daily Hospital Note/ Progress Note -Everyday a patient is in the hospital a HCP must see the patient Subjective: how patient's condition has changed assessment and plan like admission notes -SO A/P
Radiology Report 1. why the ordered a radiologic image 2.how the image was preformed 3.what was seen on the image 4.reviewing radiologist assessments *can include recommendations* -SOA
Pathology Report 1. reason for the study 2.what was seen in detail 3. the assessment -mimics radiology report -SOA
Prescriptions Line 1: Name/strenght Line 2: Marked "sig" contains patient instructions Line 3: Dispense- tells pharmacist how much medicine to give Line 4: how many refills are available Line 5: for health care provider's signature checkbox for name brand or gene
Created by: krussell92
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