HIM FPX 4610 Assessment 4 Operative Report: The Genitourinary System HIM FPX 4610 Medical Terminology

 

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Introduction

A patient’s medical records consist of various documents and forms. These include visit notes, authorizations for care, and insurance details. The four types of documentation that will be examined in the following paragraphs are progress notes, history and physical (H&P), operative reports, and discharge summaries. I will discuss the purpose of each document, its contents, and its application within a hospital or clinical setting. All of these documents are essential for maintaining a comprehensive record of the patient.

Progress Note

A progress note is a document that provides details about a patient’s visit. It includes information regarding their illness or injury, any advancements in their treatment or diagnosis, and other relevant details that may be necessary for those involved in their care. Progress notes are utilized in all hospital settings. A progress note must contain the date and time of the patient’s visit, a title for easy record retrieval, the name and role of the individual completing the note, comprehensive information about the visit, and the signature of the person who filled it out. This document is used across various clinical and hospital environments, although its format may vary from one practice to another (Columbia University, 2020).

History and Physical (H&P)

The History and Physical (H&P) document provides insights into a patient’s medical history and any findings at the time of admission. This form outlines the reason for hospitalization, an overview of the patient’s medical history, and any factors that may have contributed to their condition. It allows healthcare providers to access historical data, examination results, and care plans. This document is utilized whenever a patient is admitted (Goldberg, 2020).

Operative Report

The operative report is a document that details the information related to a surgical procedure performed on a patient. It includes the names of the surgeon and assistants, the procedures conducted, descriptions of the procedures and findings, any blood loss, specimens removed, and post-operative diagnoses. This report must be completed immediately following surgery. It is used in both outpatient and inpatient surgical facilities, including hospitals and surgical centers (Yale, 2009).

Discharge Summary

The discharge summary is a document that summarizes the patient’s history during their treatment. It includes identification details, the history of the present illness, assessments, treatment plans, progress notes, and any findings. This document can be utilized in various settings, such as therapy sessions, hospital stays, rehabilitation programs (like cardiac or neurological rehabilitation), or mental health facilities.

References

Goldberg, C. (n.d.). UCSD’s Practical Guide to Clinical Medicine. Retrieved February 19, 2020, from https://meded.ucsd.edu/clinicalmed/write.htm

Guidelines for Progress Notes. (n.d.). Retrieved