HOSPI LAB

MEDICAL RECORD o Type and duration of anesthesia used

- The purpose of the medical record is to record all the o Preoperative diagnosis
relevant information regarding the patient and a o Postoperative diagnosis
means of communication between the members of o Summary of the procedure
health care team o Amount and type of fluids including blood
transfusion
The following are the five major parts of the medical record: o Patient’s condition on leaving the OT
- Admission notes
- Operative notes
- Preoperative - Dictated and written immediately after surgery
- Operative and post-operative notes
- A summary and review of all activities that occurred
- Progress notes during surgery
- Discharge summary
o Incision
*ABC’s of writing
o Operative procedure in brief
- Accuracy
o Operative findings
- Brevity
- Clarity o Discussion of any complications
- Correcting errors o Type and location of drains
- Signing your notes o Type of suture and suturing method
o Description of pathology specimen and
ADMISSION NOTES whether it has been send for frozen section
- This explains in detail the reasons for the patient’s or routine histopathological examination
admission to the hospital - Post-operative notes
This includes the following: - Findings noted on examination of the patient 5-6
- Identifying data hours after the operation
- Chief complaint
- History of illness PROGRESS NOTES
- Past history – medical and dental - This details the progress of the patient in the hospital
- Review of systems preoperatively and postoperatively as well the drugs,
- Habits intravenous fluids to be administered daily and the
- Family history nutritional management of the patient
- Physical examination - Describes the result of the interaction of the medical
- Tentative diagnosis team with the patient post-operatively
- Plan - An outline of the course of action for any subsequent
treatments
PREOPERATIVE NOTES
- Those patients who are being prepared to undergo DISCHARGE SUMMARY
surgery under general anesthesia require pre- - It summarizes all the events that has occurred during
anesthetic consultation a day or two before surgery the patient’s stay in the hospital
- Those patients who have cardiac diseases is - Written 2 weeks after the day of discharge from the
mandatory to get a clearance of the cardiologist hospital
before sending the patient for pre-anesthetic - It generally include the following
evaluation o Name, age/date of birth, sex and address
- Similarly approval of the physician is advisable in o Referring doctor’s or hospital’s name
case of patients with systemic disease. o Date admission and discharge
o Admitting diagnosis and discharge diagnosis
OPERATIVE AND POST OPERATIVE NOTES o Name of the attending surgeon and the unit
- It summarize all events that has occurred during and o Summary of pertinent findings from history,
immediately after the surgery till the patient is physical examination and lab investigations
transferred from the operation theatre to the recovery o Consultation by specialists
room o Diagnostic and therapeutic procedures
- It consists of anesthesiologist’s notes and surgeon’s
performed
notes
o Surgery performed and date of operation
- The following points should be included in the
o Postoperative period and progress
surgeons note:
o Condition at the time of discharge
o Date
(relieved/unchanged)
o Name of the operation
o Discharge medications
o Name of surgeons and anesthesiologists
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o Discharge instructions, including follow-up o Review of pertinent clinical findings

date, diet instructions, and restriction of o Opinion regarding the present condition
activity o Suggestions/advice regarding the
management of the patient
MEDICAL RECORD o Name of the doctor or service
The following are the supporting or supplemental components o Means of contact in case of emergency
of the medical record:
- Physician’s order
- Nursing notes
M1-Lesson 2- Components of a Medical Record
- Laboratory test results
- A medical record is a collection of data compiled on
a patient to assist in the clinical care of present and
PHYSICIAN’S ORDER
future illness. By clinical care is meant treatment by
- Are systematic list of instructions by the physician to
doctors, nurses and others in the health team, in a
the floor staff for the health care plans of the patient
hospital, an outpatient clinic, or primary care by a
throughout his hospitalization
family doctor.
- In some medical record, this is written together with
- As a document, the medical record is not only a
the progress notes
repository of information, it is also a continuing
record which acts as a means of communication
NURSING NOTES
between members of the health team. A famous
- Nursing notes also forms an important part of the
maxim concerning the medical record is: "To be
medical record
complete, the medical record must contain sufficient
- They provide vital information regarding the
data, written in sequence of events, to justify the
patient’s status as seen from the view point of the
diagnosis and warrant the treatment and end results".
nurse’s approach to patient care
- But good medical records in a hospital or an
outpatient clinic do not just happen. The medical
LABORATORY RESULTS
record staff must always be trying to get cooperation
- Results of the examination of blood, urine, sputum
from doctors, nurses and other members of the health
should be entered here
team towards the prompt completion of patients'
- ECG results and blood group also should be included.
records.
Positive findings or radiographic examination, CT or
MRI scan and biopsy report also should be entered
5 MAJOR COMPONENTS OF A MEDICAL RECORD
and the full report attached to the case record.
1. Admission notes - includes the following:
- Identifying Data (ID)-- Patient's name, age, race, sex.
Name of informant (patient, relative)
CONSULTATIONS
- Chief Complaint (CC)-- Reason given by patient for
- In the management of a hospital patient the
seeking medical care and the duration of then
knowledge and skill of other specialists are often
symptom.
needed. For this the patient has to be evaluated by
- History of Present Illness (HPI) -- Describe the
other specialists and these are referred to as
course of the patient's illness, including when it
consultation
began, character of the symptoms, location where the
- The following information should be included in the
symptoms began, aggravating or alleviating factors.
request for consultation:
Describe past illnesses or surgeries, and past
o Date and time of request
diagnostic testing.
o Salutation (sir/madam/name of the - Past Medical History (PMH)--Relates the past
physician) medical conditions to current health statu Begin by
o Brief history of patient describing childhood conditions and include
o Reason for request for consultation illnesses, diseases, drug use and other factors that
o Anything special expected from consultation may contribute to the pathologic condition
o Name of requesting doctor or service - Family and Psychosocial History -- Helps identify
o Means of contact in case of emergency patterns of hereditary and acquired diseases within
consultation the patient’s family. Examines behavioral aspects of
- The doctor after examining the patient should include the patient’s daily existence. Also chronicles the
the following information in the response: patient’s beliefs, relationships, experiences, social
o The date and time of examination habits and occupational history.
o Acknowledge the request by thanking for - Physical Examination (PE) -- Requires the
the consultation competent use of the physician’s hands, eyes, ears
o Confirmation of the history of the patient and instruments. Through (PE) physical examination,
 HOSPI LAB
the physician carefully evaluates the patient’s
conditionVital signs, appearance, neurological,
musculoskeletal, dermatological and other organ
systems are recorded.
- Review of Systems (ROS)-- An orderly, systematic
progression through each system of the body that
permits health care worker to supplement subjective
information previously offered by the patient.
- Impression -- Describes the conclusion and tentative
diagnosis that have been reached based on the
information and data provided.
- Plan--A written description indicating the disposition
of the patient. Include subsequent tests and
consultations required by the physician.
2. Pre-operative notes -contain pertinent information needed
by the physician & health care team before surgery
3. Operative and Post-Operative Notes
Operative Notes
- are dictated and written immediately after surgery. A
summary & review of all activities that occurred
during surgery
Post Operative Notes and Orders
- describe findings noted on examination of the patient
5-6 hours after the operation
- Describes the:
o vital signs of the patient
o level of consciousness & activity
o Physical Exam results
o General assessment & plan of action
4. Progress notes
- Describes the result of the interaction of the medical
team with the patient post-operatively .
- An outline of the course of action for any subsequent
treatments.
5.Discharge notes
- Summary of events during the patient’s
hospitalization; Written 2 weeks after the day of
discharge from the hospital.
SUPPORTING/SUPPLEMENTAL COMPONENTS :
1.PHYSICIAN'S ORDER
- Are systematic list of instructions by the physician to
the floor staff for the health care plans of the patient
throughout his hospitalization.
2. NURSING NOTES
- Provide vital information regarding the patient’s
status as viewed by the nurse
- ***Nurses are obligated to carry out medical orders
but are also authorized to diagnose & prescribe
within the limits of the state nurse practice act.
- Nursing Care Plan
- A written guide that organizes information about the
patient’s health into one whole information.
- It is a format that nurses has to follow in charting
their interventions with the patient.
- It focuses on the actions a nurse has to take to meet
his goals for the patient.
3. LABORATORY TEST RESULTS
- Contains pertinent information extracted from blood,
urine & sputum analysis, radiographs and other
diagnostic tools.
MEDICAL TERMINOLOGIES, AND SYMBOLS
- Medical terminology is a whole new language that a
health care professionals must learn and understand.
A whole new language
- Health care workers use medical terminology and
abbreviations in their work every day.
- It is the professional language that helps them
communicate effectively and quickly
Medical Terminology
- Medical terms from prefixes, suffixes, and root
words.
o Prefix – a syllable or word placed at the
beginning of a root word.
o Suffix – a syllable or word placed at the end
of a root word.
o Word Root – main words or parts to which
prefixes and suffixes can be added.
- When prefixes, suffixes, and/or word roots are joined
together, vowels are frequently added.
o Examples: a, e, i, ia, io, o, and u.
o Combining vowels make it easier to
pronounce the term.
- There is always at least one root word and sometimes
more than one.
- When you learn the common prefixes, suffixes, and
word roots, you have the tools to combine hundreds
of medical terms.
Creating Medical Terms
- Inflammation of a joint.
o arthr is the stem that means joint.
o itis is the ending part that means
inflammation.
o Since -itis begins with a vowel, no
additional vowel on the stem will be needed.
o The medical word is arthritis.
- white (blood) cell
o leuk is the stem that means white.
o -cyte is the ending part that means cell.
o Since -cyte does not begin with a vowel, a
vowel would be added to the stem.
o leuko is the stem with the vowel.
o The medical word is leukocyte.
How to Use Medical Terminology
- A patient’s complaint of “pain in the stomach” can
mean many different things.
 HOSPI LAB

- After making a diagnosis, health care workers must A.P. anteroposterior

be able to understand exactly what the problem is. ASA aspirin
- “PAIN IN THE STOMACH” ASAP as soon as possible
o Gastritis b.i.d twice daily
o Hepatitis B.M. bowel movement
o Appendicitis B.M.R. basal metabolic rate
o Pancreatitis BP or B/P blood pressure
o Gastralgia bpm beats per minute
o Ileitis B.S.S. black silk sutures
bx biopsy
o Colitis
BMI body mass index
o Diverticulitis
BUN blood urea nitrogen
B- blood type B negative
Pronunciation
B+ blood type B positive
- Hints:
comb combination
- – ch sounds like k.
C.C. chief complaint
o Chyme, Cholecystectomy, Chronic
CBC complete blood count
- – ps sounds like s. C.H.D. congenital heart disease
o Psychiatric, Psychology, Psoriasis C.N.S. central nervous system
- – pn sounds like n. C.O.D. cause of death
o Pneumonia, Pneumatic COPD chronic obstructive pulmonary disease
- – c sounds like a soft s when it comes before e, i, and CPR cardiopulmonary resuscitation
y. C-Section Caesarean Section
o Cycle, Cytoplasm, Centrifuge CT Scan Computerized Tomography Scan
- – g sounds like j when it comes before e, i, and y. D5W Dextrose 5% water
o Giant, Gestation, Generic, Gyration defib Defibrillate
- – i sounds like “eye” when added to the end of a detox detoxification
word to form a plural. dil dilute
o Glomeruli, Villi, Alveoli, Bacilli D/C discontinue
DM Diabetes Mellitus
Medical Symbols DNR do not resuscitate
- > = greater than DOA dead on arrival
- < = less than DOB date of birth
- ↑ = higher, elevate, up DR delivery room
- ↓ = lower, down E. coli Escherichia Coli
- # = pound or number ECG Electrocardiogram
- ′ = foot minute ED Emergency Department
- ″ = inch, second EDP Emergency Department Physician
- ˚ = degree elev elevated
- F = female ENDO Endoscopy
- M = male ENT Ear , Nose, Throat
ext external
MEDICAL ABBREVIATIONS exp expired
- Shortened forms of words. excess excessive
- An efficient way of communicating quickly and F Farenheit
concisely with other health care workers. F/U or FU followup
- Always use standard abbreviations. FB foreign body
- Never use an abbreviation if you are unsure about its FBS fasting blood sugar
meaning. FDA Food and Drug Administration
fld fluid
ABG Arterial Blood gas FT feeding tube
a.c. Before meals ft foot
ACTH Adrenocorticotrophic hormone fx fracture
ad lib. at pleasure Fxl Functional
alvcty alveolectomy GERD gastroesophageal reflux disease
AMB ambulatory GI gastrointestinal
Ant. anterior Glu glucose
 HOSPI LAB

GP general practitioner neg negative

gm gram neuro neurologic
gsw gunshot wound NG TUBE nasogastric tube
gtt drop NSAIDS Non Steroidal Anti Inflammatory Drug
GTT glucose tolerance test NIDD Non Insulin depensent diabetes
grav gravida NKA no known allergy
Hr hour NKDA no known drug allergies
h.s. at bedtime or hour of sleep NS normal saline
H2O2 hydrogen peroxide NT not tested
HBP high blood pressure
HDL high density lipoprotein
HFV high frequency ventilation
Hg Mercury
Hgb hemoglobin
Hct hematocrit
Ht height
I&A irrigation and aspiration
I&D Incision and drainage
I&O input and output
Int internal
ins insertion
incr increase
inf inferior
ID identification
IM intramuscular
IV intravenous
Jt joint
JV Jugular Vein
Kg kilogram
Kcal kilocalorie
KCL Potassium Chloride
KVO keep vein open
KJ Knee jerk
KDA Known drug allergies
kV kilovolt
LOB loss of balance
LOC level of consciousness
Loc location
Lg large
LE Lower extremity
LN Lymph node
Liq liquid
LFT liver function test
LMP last menstrual period
LOM limitation on motion
MCA major coronary artery
mcg microgram
Meds medicine
Mg magnesium
Mgmt management
mI milliliter
mm millimeter
Ml myocardial infarction
Mob mobilization
MRI magnetic resonance imaging
N&V nausea & vomiting
Na sodium