Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Advanced Directives
Process of advising a patient about treatment options, risks, and benefits of treatment. Records the patients bring with them to the hospital.
Discharge Summary
Patients hospitalization, including reason for hospitalization, course of treatment, condition at discharge, patient and facility identification and admission and discharge dates. History and The patients chief complaint, Physical present illness history, past history, Examination family history, social history, current medications, and review of systems
Attending physician
Staff member who directly obtained this information from the patient
Variable between JCAHO and AOA, but usually not more than 7 days before or 48 hours after admission Not stated in the
HCR 210
Attending
Reports
based on physical examination and review of patient records. Medications and dosages
Physician Orders
Progress Notes
Notes about ongoing care: changes in the patient, complications, consultations, and treatment Preanesthesia medication administered, including time, dosage, and effect on patient. Appraisal of any changes in patients condition. Patients vital signs. Any blood loss. Iv fluids, transfusions including amount, technique used, duration. A.History, physical exam, lab and X-ray exams, and preoperative diagnosis B.Therapeutic procedures C.Postoperative evaluation
Staff who see the patient sign and attending physician countersigns
text but probably at the time of checkout or discharge Not stated in the text but probably at the time of checkout or discharge At the time they occur
Anesthesia Record
Operative Report
A. Prior to surgery B. Immediate ly after surgery C. 24 hours after surgery Within 24 hours
Pathology Report
Date of examination, clinical diagnosis, and tissue examined pathologic diagnosis, macroscopic examination, and microscopic examination. Patients condition upon arrival to recovery room, postoperative care given, level of consciousness upon entering and leaving recovery room, monitoring of vital signs. Test results from laboratories, radiology, and nuclear medicine.
Pathologist
Responsible physician or certified registered nurse. Person performing the test reports
HCR 210