Components of a Medical Record Updated 2025 with complete solution
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Components of a Medical Record
Institution
Components Of A Medical Record
Physician's progress notes - Documentation given by the physician regarding the patient's
condition, results of the physician's examination, summary of test results, plan of treatment, and
updating of data as appropriate.
Operative Report - Documentation from the surgeon detailing the operation,...
Components of a Medical Record
Physician's progress notes - Documentation given by the physician regarding the patient's
condition, results of the physician's examination, summary of test results, plan of treatment, and
updating of data as appropriate.
Operative Report - Documentation from the surgeon detailing the operation, including the
preoperative and postoperative diagnosis, specific details of the surgical procedure, how well the patient
tolerated the procedure, and any complications that occurred
Medical History (Hx) - Document describing past and current history of all medical conditions
experienced by the patient
Physical Examination (PE) - Record that includes a current head-to-toe assessment for the
patient's physical condition
Consent form - Signed document by the patient or legal guardian giving permission for treatment
Informed Consent Form - Signed document by the patient or legal guardian that explains the
purpose, risks, and benefits of a procedure and serves as proof that the patient was properly informed
before undergoing a procedure.
Physician's Orders - Record of the prescribed care, medications, tests, and treatments for a given
patient
Nurse's Notes - Record of the patient's care that includes vital signs, particularly temperature (T),
Pulse (P), Respiration (R), and blood pressure (BP). The procedures, and patient's responses to such care.
Consultation Reports - Documentation given by specialists whom the physician has asked to
evaluate the patient
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