patient chart
Clinical documentation file
A patient chart is the official record of a person's medical history, treatments, and care at a healthcare facility.
It contains diagnoses, medications, test results, vital signs, and notes from doctors and nurses.
Charts may be physical folders or electronic records: The nurse updated the patient chart after taking vitals.
In hospital settings, the chart follows the patient and serves as the primary communication tool among caregivers.
- medicalOf healthcare practice
- recordPreserved account or achievement
- attending physicianSenior doctor supervising care
- diagnosisIdentification of illness
- chief complaintPrimary reason seeking care
vitals · notes · clipboard · doctor · nurse · nursing notes · hospital · bedside · history · symptoms · vital signs · treatment · medications · allergies · labs · lab results · results · medical history
- Emergency RoomER doctor, ER nurse, triage nurse, trauma bay, gurney
- doctor's officedoctor, appointment, checkup, exam room, examination table
- hospitalizationhospital bed, hospital gown, inpatient, admission, discharge papers
- health datablood pressure, heart rate, pulse, weight, height
- intensive careventilator, ICU, life support, central line, cardiac monitor
- medical recordsmedical records, medical record, hospital records, health data, EMR
patient chartprescription
Medical dispensing authorization
treatment protocol · standing orders · formulary · treatment plan · discharge instructions
patient chartlost files
patient chartprescription
Medical dispensing authorization
treatment plan · referral form · medical directive · billing statement · consent form
patient, chart, patients, patiently, patience, impatient, impatience, impatiently, charts