Introduction to Health Records Types
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Chief Complaint | the main reason for the patient's visit
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| History of Present Illnesses | the story of the patient's problem
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| Review of Systems | description of individual body systems in order to discover any symptoms not directly related to the main problem
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| Past Medical History | other significant past illnesses, like high blood pressure, asthma, or diabetes
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| Past Surgical History | any of the patient's past surgeries
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| Family History | any significant illnesses that run in the patient's family
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| Social History | a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
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| Clinic Note | documents a visit
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| Consult Note | provides an expert opinion on a more challenging problem
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| Emergency Department Note | documents an emergency department visit
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| Admission Summary | documents the admission of a patient to the hospital
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| Discharge Summary | describes when and why the patient was admitted; documents a longer stay
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| Operative Report | documents a surgery in detail
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| Daily Hospital Note / Progress Note | documents daily hospital visit
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| Radiology Report | explains reason for image, how image was performed, what was seen on the image, radiologist's assessment; sometimes a recommendation
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| Pathology Report | provides reason for test, what was seen on the test, and an assessment
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| Prescription | provides directions for a medication
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
choover29
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