Patient's Medical Chart PDF

CONTENTS OF PATIENT’S MEDICAL CHART Age, sex, race, name, address, Social Security
PATIENT’S MEDICAL CHART Number, marital status, insurance, employer, occupation,

- a narrative or record of past events and circumstances that place of birth, religion, telephone, e.g.
are or may be relevant to a patient's current state of health. • Facts Relative to Admission.
- a comprehensive statement of facts pertaining to past and Attending physician, date and time of admission,
present health gathered, ideally from the patient room number, admitting diagnoses, anticipated procedures
1. Admission Report e.g.
2. Consent to Treatment Statements CONSENT OF TREATMENT STATEMENT
3. Attestation Statement (Attending Physician's • The statement generally puts the patient under the
Statement) control of the hospital for its care (general care,
4. Medical History nursing etc.) and under the control of the attending
5. Physician's Orders physician for such physician's care (medical and
6. Report of Physical Examination surgical procedures).
7. Progress Notes ATTESTATION STATEMENT
8. Pathology Reports • is a requirement of Medicare. It may be separate or
9. Radiology Reports it may be incorporated as part of the Admission
10. Consultation Reports Report. The Attestation contains information needed
11. Anesthesia Record by Medicare to determine reimbursements.
12. Operative Report MEDICAL HISTORY
13. Nurses’ Notes • CC
14. Vital Signs Graphics • HPI
15. Medication and Administration Record • PMH
16. Laboratory Report • Patient Medication History
17. Physical Therapy Evaluation • SH
18. Respiratory Therapy Evaluation • FH
19. Special Reports (Obstetrics, Nursery) • ROS
20. Discharge Reports. -Assist with diagnosis, treatment decisions, and
Components of Medical Chart establishment of trust and rapport between patient and
1. Medical History medical professional.
A. Patient Demographic -The information also helps determine the patient's baseline,
B. Chief Complaint (CC) or what is normal and expected for the patient.
C. History of Present Illness (HPI) PHYSICAL EXAMINATION
D. Family History (FH) • Inspection
E. Social History (SH) • Palpation
F. Allergies • Percussion
G. Medication History • Auscultation
H. Review of Systems (ROS) PHYSICIAN’S ORDERS
I. Physical Exam (PE) • These are the marching orders of the
2. Laboratory Results attending physician as regards tests, medication, treatment,
3. Diagnostic Results etc.
4. Problem List Subjective and objective findings of the physician with its
5. Clinical Notes corresponding therapeutic orders (medications, diagnostic
A. Progress notes procedures and miscellaneous orders).
B. Consultation notes PROGRESS NOTES - includes regular notes on the patient's
C. Off-service/ transfer notes status by the interdisciplinary care team.
D. Discharge Summary -Contains fields for subjective and objective findings
6. Treatment Notes assessment and plan, and diagnostic plus therapeutic
A. Medication Order information and planned date for review.
B. Surgical Procedure Documentation PATHOLOGY REPORT - document that contains the diagnosis
C. Radiation Treatments determined by examining cells and tissues under a
D. Notes from Ancillary Practitioner (Ancillary microscope.
services: laboratory, OT, PT, Speech therapy, nutrition NURSE’S NOTES - Used to document a baseline nursing
education, pulmonary testing) history and assessment for the patient.
ADMISSION REPORT (The Admission Report must be signed -Used to document accomplishment of tests, treatments, and
by the attending physician.) nursing orders.
• Patient Demographics:
|HJR2019|
-Contains fields for subjective and objective findings • Patient Medication Profile: a comprehensive
assessment and plan, and diagnostic plus therapeutic written summary of all regular medicines taken by a
information and planned date for review. patient
VITAL SIGNS RECORD - Contains fields for subjective and
objective findings assessment and plan, and diagnostic plus PATIENT MEDICATION PROFILE
therapeutic information and planned date for review. ➢ Standing Medications – current medication list of the
• Temperature patient
• Pulse rate ➢ Stat Medications – drugs for emergency purposes
• Respiratory rate ➢ Intravenous Medications – current IV therapy of the
• Blood pressure patient
Medication and Administration Record - report that serves
as a legal record of the drugs administered to a patient at a
facility by a health care professional.
DISCHARGE SUMMARY - contains final instructions for the
patient
-Summation of all activities during the patient’s course of
hospitalization
-Updated health summary contains fields for allergy, current
past medical history, current medications, and lifestyle risks.
MISCELLANEOUS PARTS
Referral Form
➢ To direct to a source for help or information
➢ To submit (a matter in dispute) to a medical
specialist/s for arbitration, decision, or examination.
Surgical Form
➢ Pre-operating diagnosis
➢ Procedure/s to be done
➢ Findings
➢ Details
➢ Recommendation
Fluid Intake and Output Chart
➢ Intake 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)
➢ Intake is any measurable fluid that goes into the
patient's body.
- fluids that are introduced through IV
➢ Output- measurable fluid that comes from the body.
- urine, drainage, vomitus (matter vomited), and
stools (fecal discharge from the bowels).
Medication and Treatment Sheet
➢ Documented by the nurse on duty to properly
identify the time of administration.
FREQUENTLY USED CHART SECTIONS INCLUDE:
• Consultations: notes from specialized 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 when leaving the facility against medical
advice (AMA).
|HJR2019|

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CONTENTS OF PATIENT’S MEDICAL CHART Age, sex, race, name, address, Social Security

PATIENT’S MEDICAL CHART Number, marital status, insurance, employer, occupation,

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