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Chapter 2 flashcards
Health record notes
| Term | Definition |
|---|---|
| Clinic Note | A health record note written by a medical professional used to document a visit in the clinic; SOAP format |
| Consult Note | a health record note written by a physician in the hospital or clinic used to provide an expert opinion on a more challenging problem; SOAP format |
| Emergency Department Note | A health record note written by ED medical staff used to document an emergency department visit; SOAP format |
| Admission Summary | A health record note written by a hospital medical professional used to document the admission of a patient to the hospital; SO A/P format |
| Discharge Summary | A health record note written by a medical professional in the hospital used to describe when and why the patient was admitted; ASOP format |
| Operative Report | A health record note written by a surgeon used to document a surgery in detail; ASOP format |
| Daily Hospital Note/ Progress Note | A health record note written by a medical professional in an inpatient health care facility used to document daily hospital visits; SO A/P format |
| Radiology Report | A health record note written by a radiologist used to explain the reason for the images, how they were performed, what was seen, and the radiologist's assessment and recommendations; SOA format |
| Pathology Report | A health record note written by a pathologist used to provide reasons for the test, what was seen, and as assessment; SOA format |
| Prescription | A health record note written by a medical professional used to provide directions for a medication; P format |
Created by:
samanthajo765