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Contents of

Patients Medical
Chart
By:
Ms. Michelle D. Bartolome, MSc

PATIENTS MEDICAL CHART


DEFINITION:
Confidential document that contains
detailed and comprehensive information
on an individual and the care experience
related to that person.

PATIENTS
MEDICAL CHART
1. Admission Report
2. Consent to Treatment Statements
3. Attestation Statement (Attending
Physician's Statement)
4. Medical History
5. Physician's Orders
6. Report of Physical Examination
7. Progress Notes
8. Pathology Reports
9. Radiology Reports
10. Consultation Reports

PATIENTS
MEDICAL CHART
11.
12.
13.
14.
15.

Anesthesia Record
Operative Report
Nurses Notes
Vital Signs Graphics
Medication and Administration
Record
16. Laboratory Report
17. Physical Therapy Evaluation
18. Respiratory Therapy Evaluation
19. Special Reports (Obstetrics,
Nursery)
20. Discharge Reports.

ADMISSION REPORT
Patient Demographics:
Age, sex, race, name, address, Social Security
Number, marital status, insurance, employer,
occupation, place of birth, religion, telephone, e.g.

Facts Relative to Admission.


Attending physician, date and time of admission,
room number, admitting diagnoses, anticipated
procedures e.g.

CONSENT OF TREATMENT
STATEMENT
The statement generally puts the patient
under the control of the hospital for its care
(general care, nursing etc.) and under the
control of the attending physician for such
physician's care (medical and surgical
procedures).References\consent to
treatment statement.pdf

ATTESTATION STATEMENT
is a requirement of Medicare. It may be
separate or it may be incorporated as part
of the Admission Report. The Attestation
contains information needed by Medicare to
determine reimbursements.
References\attestation statement.pdf

MEDICAL HISTORY

CC
HPI
PMH
Patient Medication History
SH
FH
ROS

PHYSICAL EXAMINATION

Palpation
Auscultation
Inspection
Percussion

PHYSICIANS ORDERS
These are the marching orders of the
attending physician as regards tests,
medication, treatment, etc.

PROGRESS NOTES

Patients Medical Chart

Progress notes:
includes regular notes on
the patient's status by the
interdisciplinary care
team.

PATHOLOGY REPORT

Patients Medical Chart

document that contains


the diagnosis determined
by examining cells and
tissues under a
microscope.

Medication and Administration Record

Patients Medical Chart

document that contains


the diagnosis determined
by examining cells and
tissues under a
microscope.
References\MAR.jpg

Patients Medical Chart

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).

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.

Contents of Patients Medical Charts

Surgical Form

Pre-operating diagnosis
Procedure/s to be done
Findings
Details
Recommendation
Contents of Patients Medical Charts

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)
Contents of Patients Medical Charts

Fluid Intake and Output


Chart
Intake is any measurable fluid that
goes into the patient's body.
- fluids that are introduced through IV

Contents of Patients Medical Charts

Fluid Intake and Output


Chart
Output- measurable fluid that comes
from the body.
- urine, drainage, vomitus (matter
vomited), and stools (fecal discharge
from the bowels).

Contents of Patients Medical Charts

Vital Signs Record


Temperature, pulse rate, respiratory
rate, blood pressure, urine and stool

Contents of Patients Medical Charts

Nurses Medication and


Treatment Record
Used to document a baseline nursing
history and assessment for the
patient.
Used to record identified problems
and desired results of planned nursing
intervention.
Contents of Patients Medical Charts

Nurses Notes and


Treatment Record
Used to document accomplishment of
tests, treatments, and nursing orders.

Contents of Patients Medical Charts

Medication and
Treatment Sheet
Documented by the nurse on duty to
properly identify the time of
administration.

Contents of Patients Medical Charts

Frequently used chart


sections include:
Discharge: contains final
instructions for the patient
and reports by the care
team before the chart is
closed and stored
following patient
discharge.
Patients Medical Chart

Discharge Summary
Summation of all activities during the
patients course of hospitalization
Updated health summary contains
fields for allergy, current past medical
history, current medications, and
lifestyle risks.
Contents of Patients Medical Charts

Patients Medical Chart

Frequently used chart sections


include:
Patient Medication Profile: a
comprehensive written
summary of all regular
medicines taken by a patient

Patient Medication
Profile
Standing Medications current
medication list of the patient
Stat Medications drugs for
emergency purposes
Intravenous Medications current IV
therapy of the patient
Contents of Patients Medical Charts

Contents of Patients Medical Charts

Contents of Patients Medical Charts