Question

For this activity, you should review all of the different types of records (H&P, Discharge Summary, X-Ray, etc) in chapter 6 and pay attention to the different types of information are in each record. For example, if you look at the Electroenceophalogram Report on page 194, you can see that some of the parts of the record include the Patient Age, EEG #, History, Medications, Conditions of Recording, and Impression. All of these different record parts are required in this record.

The document below contains a table that has 6 different Record Report Types (Radiology Report, Laboratory Report, Pathology Report, Operative Report, History, and Physical). Below the table you will see various parts of records. You need to cut/paste each record part under the Record Type that it belongs in (and put them in the appropriate order- although the Physical exam doesn't have a specific order). You can use your book to help you- there are pictures of all of these various types of documents in Chapter 6.

Please note, not all squares will be filled in (almost all!)

Then, upload your DRAFT document by THURSDAY. Review your classmate's submissions and see if you find any differences. Discuss these differences together to try to figure out the correct answers. Post your FINAL document on your discussion thread by the due date. I will grade your final post!

Records Parts Activity

Records Parts Activity

Radiology Report	Laboratory Report	Pathology Report	Operative Report	History	Physical

  

Indication:   

Genitalia:

Operative Findings:

History of Present Illness:

Date of Exam:

PFSH:

Gross Description:

Exam:

Postoperative Diagnosis:

Test Name:

Assistant:

Pathologic Diagnosis:

Abdomen:

Reason for Exam:

Findings:

Chest/Lungs:

Procedure Performed:

Recommendations:

Chief Complaint:

General Appearance:

Result:

Surgeon:

Complications:

Reference Range:

Indication:

Genitalia:

Operative Findings:

History of Present Illness:

Date of Exam:

PFSH:

Medications:

Preoperative Diagnosis:

Allergies:

Specimen(s) Obtained:

Review of Systems:

Microscopic Description:

HEENT:

Preoperative Diagnosis:

Impression:

Muscular System:

Flag:

Heart

Medications:

Preoperative Diagnosis:

Allergies:

Specimen(s) Obtained:

Review of Systems:

Microscopic Description:

HEENT:

Preoperative Diagnosis:

Impression:

Muscular System:

Flag:

Heart

Answer 1

Records Parts Activity: Radiology Laboratory Pathology ofetative Report History Physical Report Refort Refort Indication Test Name Indication Speamen (s) History of Genitalia Present finness - Reference obtained Pre-operative Exam - General - PFSH Appearance - Date of Range Diagnosis Microscolla Exam Result Post-operative chief complaints HEENT Description -> Reason for - microscopic I Diagnosis - Genitalia - Muscular Syster Impression Exam. Description operative findings Review of - Heart - Date of »PISH - systems Exam - Allergies ->Recommendations - Gooss Procedure Performed - HEENT y Chest Lungs Description Surgeon Muscular system - Flag - Abdomen - Allergies - Pre-operatie Complications - Pathologec Diagnoss - Medications Diagnosis Impression -Pre-operative Diagnosis - Findings Flag Assistant - Impression