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.