MT Types of Medical Reports

Nurse notes

• report that nurse writes to talk about the patient's vital signs, treatment, reactions to treatments, etc.

• report that nurse writes to talk about the social and family history of the patient

• report written by pathologist

Hospice

• report that nurse writes to talk about the patient's vital signs, treatment, reactions to treatments, etc.

• Provides supportive care to terminally ill patients and families

• report written by pathologist

Discharge summary report

• report that nurse writes to talk about the patient's vital signs, treatment, reactions to treatments, etc.

• Provides supportive care to terminally ill patients and families

• A brief summary of the significant events of a pt's hospitalization; for when patient is discharged from hospital

Physician's Progress Notes

• Documentation given by the Nurse regarding the patient's condition, results of the physician's examination, summary of test results, plan of treatment, and updating of data as appropriate

• Documentation given by the Pathologist regarding the patient's condition, results of the physician's examination, summary of test results, plan of treatment, and updating of data as appropriate

• 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

Outpatient Care

• services that do not require the patient to stay overnight in the hospital

• services that require the patient to stay overnight in the hospital for a few days

• 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

Diagnostic Report

• services that do not require the patient to stay overnight in the hospital

• Results of all diagnostic tests performed on the patient, from lab to medical imaging

• 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

Long Term Care Facility

• services that do not require the patient to stay overnight in the hospital

• Results of all diagnostic tests performed on the patient, from lab to medical imaging

• Provide assistance and care to the elderly

History & Physical (H & P)

• information about the future plans of the patient

• The pertinent information about the patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems

• Provide assistance and care to the elderly

Acute Care

• Provides services for a short period of time

• Provides services for a chronic disease for a long period of time

• Provide assistance and care to the elderly

Pathologist's Report

• report given by nurse to the next shift's nurse

• report given by pathologist who studies tissue removed from patient

• report given by nurse who takes care of long term care patient