Components of a Medical Record Updated 2025 with complete solution

Physician's progress notes - Documentation given by the physician regarding the patient's condition, results of the physician's examination, summary of test results, plan of treatment, and updating of data as appropriate. Operative Report - Documentation from the surgeon detailing the operation, including the preoperative and postoperative diagnosis, specific details of the surgical procedure, how well the patient tolerated the procedure, and any complications that occurred Medical History (Hx) - Document describing past and current history of all medical conditions experienced by the patient Physical Examination (PE) - Record that includes a current head-to-toe assessment for the patient's physical condition Consent form - Signed document by the patient or legal guardian giving permission for treatment Informed Consent Form - Signed document by the patient or legal guardian that explains the purpose, risks, and benefits of a procedure and serves as proof that the patient was properly informed before undergoing a procedure. Physician's Orders - Record of the prescribed care, medications, tests, and treatments for a given patient Nurse's Notes - Record of the patient's care that includes vital signs, particularly temperature (T), Pulse (P), Respiration (R), and blood pressure (BP). The procedures, and patient's responses to such care. Consultation Reports - Documentation given by specialists whom the physician has asked to evaluate the patientAncillary/Miscellaneous reports - Documentation of procedures or therapies provided during a patient's care, such as physical therapy, respiratory therapy, or chemotherapy Diagnostic Tests/Laboratory Reports - Documents providing the results of all diagnostic and laboratory tests performed on the patient Anesthesiology Report - Documentation from the attending anesthesiologist or anesthetist that includes a detailed account of anesthesia during surgery, which drugs were used, dose and time given, patient response, monitoring of vital signs, how well the patient tolerated the anesthesia, and any complications that occurred. Patient Information Form - Document that is filled out by the patient on the first visit to the physician's office and then updated as necessary, providing data that relates directly to the patient, including last name, first name, gender, DOB, marital status, street address, city, state, zip code, telephone number, social security number, employment status, address and phone number of employer,name and contact information for the person who is responsible for the patient's bill, and vital information for the person who is responsible for the patient's bill, and vital information concerning who should be contacted in case of an emergency Pathology Report - Documentation from the pathologist regarding the findings or results of samples taken from the patient, such as bone marrow, blood, or tissue Discharge Summary - Outline summary of the patient's hospital care, including date of admission, diagnosis, course of treatment and patient's response(s), results of tests, final diagnosis, follow-up plans, and date of discharge