M. Sc. Karelia R. Choque Nina
Year: I / 2022 ENGLISH I
1
20 Types of Medical Records
https://quizlet.com/90618922/types-of-medical-records-flash-cards/
1.
Patient Information
Form (Patient Data)
(p. 27)
Document that is filled out by the patient on the first visit to the
physician's office and then updated as necessary, providing data
that relates directly to the patient, including last name, first
name, gender, DOB (date of birth), marital status, street
address, city, state, zip code, telephone number, social security
number, employment status, address and phone number of
employer, name and contact information for the person who is
responsible for the patient's bill, and vital information for the
person who is responsible for the patient's bill, and vital
information concerning who should be contacted in case of an
emergency
2.
EHR
Electronic health record that keeps basic profile information on
a patient.
3.
Medical History (Hx)
(p. 28)
Document describing past and current history of all medical
conditions experienced by the patient.
4.
Physical Examination
(PE)
Record that includes a current heat-to-toe assessment of the
patient's physical condition.
5.
Consent Form
Signed document by the patient of legal guardian giving
permission for treatment.
6.
Informed Consent
Form
Signed document by the patient of legal guardian that explains
the purpose, risks, and benefits of a procedure and serves as
proof that the patient was properly informed before undergoing
a procedure.
7.
Physician's Orders
Record of the prescribed care, medications, tests, and
treatments for a given patient.
8.
Nurse's Notes
Record of a patient's health care that includes vital signs,
particularly TPR (temperature, Pulse, Respiration) and BP
(blood pressure). The notes can also include treatments,
procedures, and patient's responses to such care.
9.
Physician's Progress
Notes
Documentation given by physician regarding the patient's
condition, results of the examination, summary of test results,
plan of treatment, and updating data as appropriate. (Dx)
