Term | Definition |
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 |