Introduction to Patient_s Medical Chart (2012).pdf

7/24/2019 Introduction to Patient_s Medical Chart (2012).pdf

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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.

Contents of Patients Medical Charts


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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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ChartIntake is any measurable fluid that

goes into the patient's body.

- fluids that are introduced through IV



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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.

Patients Medical Chart


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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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Documents

Introduction to Patient_s Medical Chart (2012).pdf