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Health Records

TermDefinition
Clinic Note Used when a patient is seen in an OFFICE setting; visit must be documented. Can be handwritten, dictated or electronic
Consult Note A note from a visit to a specialist or consultant; specialist may prefer to write the note to the PCP
Emergency Dept Note Used when patients are seen in EDs and Urgent Cares; explains what happened to the patient during their stay in the ED
Admission Summary Heavy on subjective AND objective parts to help hospital stay; patients will give medical history
Discharge Summary Explains when and why a patient was admitted; includes how the patient felt when admitted and what happened during the patients stay at the hospital
Operative Report Completed by a surgeon; outlines the procedure that was done, the events that transpired during the surgery and the patient's outcome
Daily Hospital Note Daily note; focuses on how the patient's condition has changed since the previous note
Radiology Report explains the reason for ordering a radiologic image, how the image was performed, and what was seen on the image
Pathology Report mirrors the radiology note; mentions the reason for the study, what was seen in detail and the assessment
Prescription is the PLAN; name & strength of the medicine, patient's instructions, how much, and health care providers signature
Created by: jiliavaje16
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