patient charts
Hospital documentation folders
Patient charts are the official records documenting a person's medical history, treatments, and care.
In hospitals and clinics, charts contain vital signs, diagnoses, medications, test results, and notes from healthcare providers.
To chart is to record information in these records: The nurse charted the patient's blood pressure.
Charts may be physical folders or electronic files.
- care plansOrganized healthcare strategies
- data entryRecording information digitally
- medical historyRecord of past ailments
- audit trailsRecorded history of actions
- consent formsWritten permission documents
nursing notes · progress notes · risk assessments · imaging studies · discharge summary · medication list · vital signs · lab results · cloud storage · HIPAA
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- medical recordsmedical records, medical record, hospital records, health data, EMR
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- office equipmentprinter, printers, copier, copiers, scanner
- nursing suppliesbreast pump, breast pads, nursing bra, nursing pads, nursing pillow
patient chartsmedical treatment
Care for illness
clinical intervention · surgical procedure · patient care · bedside manner · medical procedures
patient chartsprescriptions
Authorized medication orders
doctor's orders · care instructions · discharge instructions · treatment plans · standing orders
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