what is the order of tabs in composing a medical chart?  

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The following are the standard sections found in hospital medical charts.  In any given chart, some of the sections may be absent, depending on the nature of the illness, circumstances, treatments, outcome and the complexity of the hospitalization.

Admission Paperwork

Consultations

ER visits

History and Physical

Discharge Summary

Consultations

Doctors’...

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The following are the standard sections found in hospital medical charts.  In any given chart, some of the sections may be absent, depending on the nature of the illness, circumstances, treatments, outcome and the complexity of the hospitalization.

Admission Paperwork

Consultations

ER visits

History and Physical

Discharge Summary

Consultations

Doctors’ Orders

Doctors’ Progress Notes

Nurses’ Notes

Operative Reports

Laboratory and Pathology Reports

Radiology (X-ray) Reports

EKG Reports

Medication Record

Physical and Occupational Therapy

Autopsy Report

 

Doctor’s Office Charts are somewhat more abbreviated and have fewer sections, a typical example as follows:

Patient Demographic Information

Consents

Insurance Information

Summary of Visits

Initial Consultation

History and Physical Examination

Doctor’s Notes for each visit

Laboratory Reports

Radiology (X-ray) Reports

Prescriptions

Consultation Reports

Discharge Summaries for hospitalizations

 

 

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