Immunizations This report provides the information of the immunizations that the patient has had at The hospital. Discharge summary This report is completed after the patient is discharged from the hospital. The report is a summary of the admission to the hospital, care provided, the diagnosis, procedures, medications, tests, immunizations, any problems and the plan for care after discharge from the hospital. History and physical (H&P) The history and physical report is completed for every hospital admission. It gives a detailed physical examination of the patient, the history of the present illness, the family medical history, the social history and a summary of the suspected causes of the patient’s illness. Operative report (Op report) This report is created for every major surgical procedure for a patient. It includes the diagnosis before and after surgery as well as a detailed summary of the actual procedure. Lab results These are reports that contain the results of lab tests the patient has had. These results can take a while to appear in the medical record based on how long it takes to process the lab specimen. Pathology report If the patient had something removed during an operation, the laboratory produces an evaluation of the tissue. This report can take a while to appear in the medical record because the evaluation can take several days. Medication reconciliation This form is required both at admission to the hospital and discharge from the hospital. It lists all the medications the patient takes or needs to take at home. Consultations Often, a patient will require the advice of an expert physician, called a consultant. The consultant must complete a report of the visit and examination. This report is a specialized history and physical examination that focuses on a particular problem or diagnosis. Discharge instructions This form is completed for every patient who has stayed in the hospital. It lists diagnosis, diet limitations, activity limitations and follow-up visit instructions. Outpatient visit Documentation This report is completed for patients seen in our clinic or outpatient settings. The report may contain a summary of the reason for the visit, problems, physical examination, immunizations, tests ordered, care provided, medications, treatment plan and follow-up care.
The 1st option is all true- history, timeline of care, treatments, medications, test results, diagnosis.
2nd and 3rd not true, would not include financial information.
4th option could include insurance information but it’s not typical unless asked for and patient complaints (say, if a patient emailed the doctor and complained about something, the email would have to be scanned into the chart and saved into their file... medical record).
1 and 4 could be true, but 1 is very typical, 4th answer would be the next level. I would pick 1.
True- an involuntary reflex is a reaction that happens when something else occurs. A involuntary reflex is something our body is “programmed” to do automatically.
Doctors believe that diet, medical care, and other lifestyle decisions affect fetal development later in pregnancy. Certain genetic factors can influence things like fetal growth, but this is most shown in the first trimester. Doctors and nutrition experts suggest improving nutritional health several months to a year before planning to become pregnant. Improper nutrition, stress, and overreliance on caffeine, nicotine, or other substances can sometimes impact fertility.
