M4 - types of documents Flashcards Preview

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Flashcards in M4 - types of documents Deck (42)
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1

patient registration record

administrative

2

consents / authorizations

administrative

3

property / valuables list

administrative

4

transfer / referral form

administrative

5

death / birth certificates

administrative

6

surgical booking form

administrative

7

anaesthesia record

operative

8

operative report

operative

9

pathology report

operative

10

recovery room record

operative

11

pre-op nursing checklist

operative

12

operating room record (nursing)

operative

13

surgical count sheet (nursing)

operative

14

discharge summary

physician

15

discharge summary narrative

physician

16

emergency record

physician

17

problem list

physician

18

history & physical exam

physician

19

progress notes

physician

20

progress notes

physician

21

physician's orders

physician

22

consultation report

physician

23

acute pain assessment

physician

24

cardiac arrest

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