M4 - types of documents Flashcards
1
Q
patient registration record
A
administrative
2
Q
consents / authorizations
A
administrative
3
Q
property / valuables list
A
administrative
4
Q
transfer / referral form
A
administrative
5
Q
death / birth certificates
A
administrative
6
Q
surgical booking form
A
administrative
7
Q
anaesthesia record
A
operative
8
Q
operative report
A
operative
9
Q
pathology report
A
operative
10
Q
recovery room record
A
operative
11
Q
pre-op nursing checklist
A
operative
12
Q
operating room record (nursing)
A
operative
13
Q
surgical count sheet (nursing)
A
operative
14
Q
discharge summary
A
physician
15
Q
discharge summary narrative
A
physician
16
Q
emergency record
A
physician
17
Q
problem list
A
physician
18
Q
history & physical exam
A
physician
19
Q
progress notes
A
physician
20
Q
progress notes
A
physician
21
Q
physician’s orders
A
physician
22
Q
consultation report
A
physician
23
Q
acute pain assessment
A
physician
24
Q
cardiac arrest
A
physician
25
nursing notes
nursing
26
graphic record / flow sheets
nursing
27
fluid balance record
nursing
28
medication sheet
nursing
29
special care units
nursing
30
Therapies (PT/OT/Speech)
ancillary/interdisciplinary
31
dietician / nutritionist
ancillary/interdisciplinary
32
social services
ancillary/interdisciplinary
33
radiation therapy
ancillary/interdisciplinary
34
pulmonary function
ancillary/interdisciplinary
35
respiratory therapy
ancillary/interdisciplinary
36
blood crossmatch/administration
ancillary/interdisciplinary
37
imaging reports (xray/nuc med/ultra)
diagnostic reports
38
echocardiograms
diagnostic reports
39
laboratory reports
diagnostic reports
40
ecg / eeg / emg
diagnostic reports
41
pathology report
diagnostic reports
42
autopsy report
diagnostic reports
