Documents Common to Most Health Records

 

• Identification Sheet - forms lists your name, address, telephone number, insurance information.
• History and Physical - describes any major illnesses and surgeries you have had, significant family history of diseases, current medications, and current symptoms.
• Progress notes - notes made by doctor, nurses, and therapists caring for you , their observation and plans for continued treatment.
• Consultation - opinion about your condition made by a physician other than your primary care physician.
• Physician's Orders - physician's directions to other members of the healthcare team regarding your medications, tests, diet, and treatment.
• X-ray reports - describing x-ray results. The actual films are maintained in radiology department.
• EKG - cardiologist's interpretation of graphic tracings that represent the electrical changes in heart as it beats.
• Lab reports - results of tests conducted.Your blood type is not part of routine lab work.
• Operative report - document describing surgery performed.
• Anesthesia report - document containing preoperative medication, and anesthesia given.
• Pathology report - describes tissue removed during an operation (if any) and gives a diagnosis based on examination of that tissue.
• Recovery room record - documents your condition from when you leave the operating room until you arrive on the nursing unit.
• Discharge summary - concise summary of your stay including reason for admission, procedures performed, therapies provided, response to treatment and condition at discharge.