Contents of

Patient’s Medical
Chart
PATIENT’S MEDICAL CHART
DEFINITION:
- a narrative or record of past events and
circumstances that are or may be relevant
to a patient's current state of health.
- a comprehensive statement of facts
pertaining to past and present health
gathered, ideally from the patient
 PATIENT’S
MEDICAL CHART
1. Admission Report
2. Consent to Treatment Statements
3. Attestation Statement (Attending
Physician's Statement)
4. Medical History
5. Physician's Orders
6. Report of Physical Examination
7. Progress Notes
8. Pathology Reports
9. Radiology Reports
10. Consultation Reports
 PATIENT’S
MEDICAL CHART
11. Anesthesia Record
12. Operative Report
13. Nurses’ Notes
14. Vital Signs Graphics
15. Medication and Administration
Record
16. Laboratory Report
17. Physical Therapy Evaluation
18. Respiratory Therapy Evaluation
19. Special Reports (Obstetrics,
Nursery)
20. Discharge Reports.
 ADMISSION REPORT
• Patient Demographics:
Age, sex, race, name, address, Social Security
Number, marital status, insurance, employer,
occupation, place of birth, religion, telephone, e.g.
• Facts Relative to Admission.
Attending physician, date and time of admission,
room number, admitting diagnoses, anticipated
procedures e.g.
 CONSENT OF TREATMENT
STATEMENT

• The statement generally puts the patient

under the control of the hospital for its care
(general care, nursing etc.) and under the
control of the attending physician for such
physician's care (medical and surgical
procedures).
CONSENT OF TREATMENT
STATEMENT
 ATTESTATION STATEMENT

• is a requirement of Medicare. It may be

separate or it may be incorporated as part
of the Admission Report. The Attestation
contains information needed by Medicare to
determine reimbursements.
ATTESTATION STATEMENT
 MEDICAL HISTORY

• CC
• HPI
• PMH
• Patient Medication History
• SH
• FH
• ROS
PHYSICAL EXAMINATION

• Inspection
• Palpation
• Percussion
• Auscultation
 PHYSICIAN’S ORDERS

• These are the marching orders of the

attending physician as regards tests,
medication, treatment, etc.
PROGRESS NOTES
• Progress notes:
includes regular notes on

Patient’s Medical Chart

the patient's status by the
interdisciplinary care
team.
PATHOLOGY REPORT
• document that contains
the diagnosis determined

Patient’s Medical Chart

by examining cells and
tissues under a
microscope.
NURSE’S NOTES
• Used to document a baseline
nursing history and

Patient’s Medical Chart

assessment for the patient.
• Used to document
accomplishment of tests,
treatments, and nursing
orders.
VITAL SIGNS RECORD
• Temperature
• Pulse rate

Patient’s Medical Chart

• Respiratory rate
• Blood pressure
 Patient’s Medical Chart
VITAL SIGNS RECORD
Medication and Administration Record

• report that serves as a

legal record of

Patient’s Medical Chart

the drugs administered to
a patient at a facility by a
health care professional.
Medication and Administration Record

Patient’s Medical Chart

DISCHARGE SUMMARY
• contains final instructions for the
patient
• Summation of all activities during

Patient’s Medical Chart

the patient’s course of
hospitalization
• Updated health summary contains
fields for allergy, current past
medical history, current
medications, and lifestyle risks.
Miscellaneous Parts
Contents of Patient’s Medical Charts
 Referral Form
 To direct to a source for help or
information
 To submit (a matter in dispute) to a
medical specialist/s for arbitration,
decision, or examination.

Contents of Patient’s Medical Charts

 Surgical Form

 Pre-operating diagnosis
 Procedure/s to be done
 Findings
 Details
 Recommendation

Contents of Patient’s Medical Charts

 Fluid Intake and Output
Chart
Intake is any measurable fluid that
goes into the patient's body.
- fluids (such as water, soup, and fruit
juice).
- "solids" composed primarily of
liquids (such as ice cream and gelatin)

Contents of Patient’s Medical Charts

 Fluid Intake and Output
Chart
Intake is any measurable fluid that
goes into the patient's body.
- fluids that are introduced through IV

Contents of Patient’s Medical Charts

 Fluid Intake and Output
Chart
 Output- measurable fluid that comes
from the body.
- urine, drainage, vomitus (matter
vomited), and stools (fecal discharge
from the bowels).

Contents of Patient’s Medical Charts

 Medication and
Treatment Sheet
 Documented by the nurse on duty to
properly identify the time of
administration.

Contents of Patient’s Medical Charts

 Frequently used chart sections
include:
• Consultations: notes from
specialized diagnosticians or care
Patient’s Medical Chart

providers.
• Consents: includes permissions
signed by patient for procedures,
tests, or access to chart. May also
contain releases, such as the
release signed by the patient when
leaving the facility against medical
advice (AMA).
 Frequently used chart sections
include:
• Patient Medication Profile: a
comprehensive written
Patient’s Medical Chart

summary of all regular

medicines taken by a patient
 Patient Medication
Profile
 Standing Medications – current
medication list of the patient
 Stat Medications – drugs for
emergency purposes
 Intravenous Medications – current IV
therapy of the patient

Contents of Patient’s Medical Charts

Contents of Patient’s Medical Charts – PMP
Contents of Patient’s Medical Charts – PMP