Patient Medical Record

The patient medical record generally includes some or most of the following types of forms or topic-specific electronic screens:

1. Admission/Discharge record, sometimes referred to as the "face sheet"
2. Admission Consent form/Specialized consent forms
3. Medical history
4. Physical examination
5. Physician Progress notes
6. Progress notes of other clinicians treating the patient
7. Physician orders
8. Operative Reports
9. Anesthesiology record
10. Recovery Room record
11. Pathology report
12. Lab reports/test results
13. Radiology reports/test results
14. Nursing notes
15. Nursing graphic record
16. Nursing medication record
17. Ancillary reports/findings