Patients

Medical
Chart

Bea Victoria T. Gumapac, RPh

Other Terms: Medical Records, Health Record

By DEFINITION:
Confidential document that contains detailed and
comprehensive information on an individual and the care
experience related to that person.
 Documenting communication among the health professionals
contributing to care and services provided to the patient.
Provides continuity of patient care
Basis for planning patient care
Protective documents of the patient and health care professional
responsible for the patients care
Provide data for medical research and to educate medical
students and other health care provider
Frequently Used Chart Sections

1. Admission Form (Patient Data Sheet)

2. History and Physical
3. Orders
4. Medical Record
5. Treatment Record
6. Procedures
7. Progress Notes
Frequently used Chart Sections

8. Consultations
9. Consents
10. Patient Medication Profile
11. Flow records
12. Care plans
13. Discharge
14. Insurance Information
 Contents of Patients
Medical Chart
1. Admission Form (Patient Data Sheet)
2. Patient Medication Profile
3. Medical History
4. Review of Systems
5. Problem List
6. Referral Form
7. Surgical Form
 Contents of Patients
Medical Chart
8. Progress Notes
9. Fluid Intake and Output Chart
10. Vital Signs Record
11. Nurses Notes and Treatment Record
12. Physicians Order Sheet
13. Standing Order Sheet
14. Medication and Treatment Sheet
15. Nurses Medication Notes
16. Discharge Summary
Admission Form
Name
Address
Contact number and person
Age
Date and Place of Birth
Occupation
Status
Patient Hospital Number
Patients health insurance
Patient Medication Profile

Standing medications current medication list

Stat medications for emergency purposes
Intravenous medications current IV therapy
Medical History
Current collection of organized information unique to the
individual patient.
Biographical, demographic, physical, mental, emotional,
sociocultural, sexual, and spiritual data.
Assist with diagnosis, treatment decisions, and establishment
of trust and rapport between patient and medical
professional.
The information also helps determine the patient's baseline,
or what is normal and expected for the patient.
Medical History

Personal and Social History

Past History
Family History
Review of Systems

Lists presence or absence of common symptoms related to each

major body system

Physical Examination
Palpitations
Percussion
Auscultation
Smell
Problem List
Working diagnosis
List of all identified disease condition
Referral Form
To direct to a source for help or information
To submit (a matter in dispute) to a medical specialist/s for
arbitration, decision, or examination.
Surgical Form
Pre-operating diagnosis
Procedure/s to be done
Findings
Details
Recommendation
Progress Notes

Contains fields for subjective and objective findings assessment

and plan, and diagnostic plus therapeutic information and planned
date for review.
Fluid Intake and Output Chart
Intake is any measurable fluid that goes into the patient's body.
fluids (such as water, soup, and fruit juice).
"solids" composed primarily of liquids (such as ice cream and
gelatin)
Intake is any measurable fluid that goes into the patient's body.
fluids that are introduced through IV
Output- measurable fluid that comes from the body.
urine, drainage, vomitus (matter vomited), and stools (fecal
discharge from the bowels).
Vital Signs Record
Temperature, pulse rate, respiratory rate, blood pressure, urine
and stool
Nurses Notes and Treatment Record
Used to document a baseline nursing history and assessment for
the patient.
Used to record identified problems and desired results of planned
nursing intervention.
Used to document accomplishment of tests, treatments, and
nursing orders.
Physicians Order Sheet
Subjective and objective findings of the physician with its
corresponding therapeutic orders (medications, diagnostic
procedures and miscellaneous orders).
Standing Order Sheet
Routine orders of the physician or the specialists after the
procedure was done
Medication and Treatment Sheet
Documented by the nurse on duty to properly identify the time of
administration
Nurses Medication Notes
Consists of a reason why does the drug/s not given
Discharge Summary
Summation of all activities during the patients course of
hospitalization
Updated health summary contains fields for allergy, current past
medical history, current medications, and lifestyle risks.
Thank you

Always be the best version of you.