Problem:
The physician may want to view the following documentation:
Administrative Data-entails the patient's confidential personal information such as contact information, insurance, and anything that would validate the patients true identity. As a result of seeing a wide array of patients, physicians, nurses, etc. want to make sure that there are no mix-ups with placing the wrong chart with the wrong patient.
History and Physical report-this consists of a collection of information that includes a detailed account of the patients' past and present illnesses. This section would also include diagnoses of current problematic symptoms.
Progress Notes-This segment of the hospitalized chart would include new developments in the patients' condition. The physician will monitor the patients' progress after the lab results, and additional tests have been analyzed.
Nurse Notes-Monitor of the patients' daily routine, nutrition, and or vital statistics. In this section a nurse may make recommendations for the attending physician (Novak & Davis, 2004). These notes would include a patients' blood panel, and information regarding which cells are active in the patient and which cells are depleting.
Lab Results-would include a comparison of white blood count (WBC) to red blood cells (RBC), whether the patients' blood count are normal or abnormal. The lab test would include, PT, PTT, CBC, RBC, (Cultures) Urinalysis, Stool, Hct, et cetera. These results would identify any bacteria, diseases, infections, or any abnormalities in the blood and/or urine.
Radiology Reports-CT's, MRI's, and X-Ray's. Each report identifies issues that may arise within the musculoskeletal system.
Physicians Orders-abbreviated notes of instruction of what the physician concluded would be the best method of treatment, it would also include medication prescribed and the times of day the patient is required to take medication.