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Contents of
Patients Medical
Chart
By:
Ms. Michelle D. Bartolome, MSc
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PATIENTS MEDICAL CHART
DEFINITION:
Confidential document that contains
detailed and comprehensive information
on an individual and the care experience
related to that person.
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PATIENTS
MEDICAL CHART1. Admission Report2. Consent to Treatment Statements
3. Attestation Statement (Attending
Physician's Statement)
4. Medical History
5. Physician's Orders
6. Report of Physical Examination
7. Progress Notes
8. Pathology Reports
9. Radiology Reports
10. Consultation Reports
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PATIENTS
MEDICAL CHART11.Anesthesia Record12. Operative Report
13. Nurses Notes
14. Vital Signs Graphics
15. Medication and Administration
Record
16. Laboratory Report
17. Physical Therapy Evaluation
18. Respiratory Therapy Evaluation
19.Special Reports (Obstetrics,
Nursery)
20. Discharge Reports.
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ADMISSION REPORT
Patient Demographics:Age, sex, race, name, address, Social Security
Number, marital status, insurance, employer,
occupation, place of birth, religion, telephone, e.g.
Facts Relative to Admission.
Attending physician, date and time of admission,
room number, admitting diagnoses, anticipatedprocedures e.g.
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CONSENT OF TREATMENT
STATEMENT
The statement generally puts the patient
under the control of the hospital for its care
(general care, nursing etc.) and under the
control of the attending physician for such
physician's care (medical and surgical
procedures).References\consent to
treatment statement.pdf
http://localhost/var/www/apps/conversion/tmp/scratch_5/References/consent%20to%20treatment%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/consent%20to%20treatment%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/consent%20to%20treatment%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/consent%20to%20treatment%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/consent%20to%20treatment%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/consent%20to%20treatment%20statement.pdf -
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ATTESTATION STATEMENT
is a requirement of Medicare. It may be
separate or it may be incorporated as part
of the Admission Report. The Attestation
contains information needed by Medicare to
determine reimbursements.
References\attestation statement.pdf
http://localhost/var/www/apps/conversion/tmp/scratch_5/References/attestation%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/attestation%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/attestation%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/attestation%20statement.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/attestation%20statement.pdf -
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MEDICAL HISTORY
CC
HPI
PMH Patient Medication History
SH
FH
ROS
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PHYSICAL EXAMINATION
Palpation
Auscultation
Inspection Percussion
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PHYSICIANS ORDERS
These are the marching orders of the
attending physician as regards tests,
medication, treatment, etc.
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PROGRESS NOTES
Progress notes:includes regular notes on
the patient's status by the
interdisciplinary careteam.
Pat
ientsMedicalCha
rt
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PATHOLOGY REPORT
document that containsthe diagnosis determined
by examining cells and
tissues under amicroscope.
Pat
ientsMedicalCha
rt
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Medication and Administration Record
document that containsthe diagnosis determined
by examining cells and
tissues under amicroscope.
References\MAR.jpg
Pat
ientsMedicalCha
rt
http://localhost/var/www/apps/conversion/tmp/scratch_5/References/MAR.jpghttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/MAR.jpghttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/MAR.jpghttp://localhost/var/www/apps/conversion/tmp/scratch_5/References/MAR.jpg -
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Frequently used chart sectionsinclude:
Consultations: notes fromspecialized diagnosticians or care
providers.
Consents:includes permissions
signed by patient for procedures,
tests, or access to chart. May also
contain releases, such as the
release signed by the patient whenleaving the facility against medical
advice (AMA).PatientsMedicalChart
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Referral FormTo direct to a source for help or
information
To submit (a matter in dispute) to amedical specialist/s for arbitration,
decision, or examination.
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Surgical Form
Pre-operating diagnosis
Procedure/s to be doneFindings
Details
Recommendation
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Fluid Intake and Output
ChartIntake is any measurable fluid that
goes into the patient's body.
- fluids (such as water, soup, and fruit
juice).
- "solids" composed primarily of
liquids (such as ice cream and gelatin)
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Fluid Intake and Output
ChartIntake is any measurable fluid that
goes into the patient's body.
- fluids that are introduced through IV
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Fluid Intake and Output
ChartOutput- measurable fluid that comes
from the body.
- urine, drainage, vomitus (matter
vomited), and stools (fecal discharge
from the bowels).
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Vital Signs Record
Temperature, pulse rate, respiratory
rate, blood pressure, urine and stool
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Nurses Medication and
Treatment RecordUsed to document a baseline nursing
history and assessment for the
patient.Used to record identified problems
and desired results of planned nursing
intervention.
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Nurses Notes and
Treatment Record Used to document accomplishment of
tests, treatments, and nursing orders.
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Medication and
Treatment SheetDocumented by the nurse on duty to
properly identify the time of
administration.
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Frequently used chartsections include:
Discharge: contains final
instructions for the patient
and reports by the careteam before the chart is
closed and stored
following patient
discharge.
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Discharge Summary
Summation of all activities during the
patients course of hospitalization
Updated health summary contains
fields for allergy, current past medical
history, current medications, and
lifestyle risks.
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Frequently used chart sectionsinclude:
Patient Medication Profile: acomprehensive written
summary of all regular
medicines taken by a patient
PatientsMedicalChart
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Patient Medication
ProfileStanding Medicationscurrent
medication list of the patient
Stat Medicationsdrugs foremergency purposes
Intravenous Medicationscurrent IV
therapy of the patient
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Contents of Patients Medical Charts