Topics of this game:
- The information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services.
- The portion of clinical data addresses the patient's current complaints and symptoms and describes his or her past medical, personal, and family history.
- The physician's assessment of the patient's current health status after evaluating after evaluating the patient's current health condition.
- The instructions the physician gives to other healthcare professionals who perform diagnostic tests and treatments, administer medications, and provide specific services to a particular patient.
- Orders the medical staff or an individual physician established as routine care for a specific diagnosis or procedure.
- The comments of physicians, nurses and other caregivers that create a chronological report of the patient's condition and response to treatment during his or her hospital stay.
- Notes that serve to justify further acute-care treatment in healthcare organizations
- A summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for interventions.
- A description of the examination of a patient's body after he or she has died.
- The entire procedure itself is recorded along with an anesthesia record, an op report and a post-anesthesia report.
- Any preoperative medication and the response to it, the dosage of the anesthesia administered and the route of administration
- Describes in detail the surgical procedures performed on a patient
- Dictated by a pathologist after examination of tissue received for evaluation.
- Documents the clinical opinion of a physician other than the primary or attending physician.
- A concise account of the patient's illness, course of treatment, response to treatment and condition at the time of patient discharge from the hospital.
- When a patient is being transferred from the acute care setting to another healthcare organization.
- Coded information contained in secondary records describing patient identification and insurance.
- Tests and procedures sometimes ordered by a physician.
- A format in which the documentation is organized by source or originating department.
- The information is placed in chronological order regardless of the source.
- A format which defines and documents clinical problems individually.
- Health records contain 2 different types of info:
