Across
- 6. Document describing past and current history of all medical conditions experienced by the patient
- 7. Record of the prescribed care, medications, tests, and treatments for a given patient.
- 8. A signed document by the patient or legal guardian giving permission for treatment.
- 9. Outline summary of the patient’s hospital care, including date of admission, diagnosis, course of treatment and patient’s response(s), test results, final diagnosis, follow-up plans, and date of discharge.
- 10. Set of rules that doctors, healthcare facilities, and other healthcare providers must follow to help ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling, and privacy
- 11. Record of a patient’s care that includes vital signs, particularly temperature, pulse and respiration (T P R), and blood pressure (B P), and treatments, procedures, and patient’s responses to such care.
- 12. Documents providing the results of all diagnostic and laboratory tests performed on the patient.
- 13. Documentation from the pathologist regarding the findings or results of samples taken from the patient, such as bone marrow, blood, or tissue.
Down
- 1. Documentation of procedures or therapies provided during a patient’s care, such as physical therapy, respiratory therapy, or chemotherapy.
- 2. Documentation from the surgeon detailing the operation, including the preoperative and postoperative diagnosis, specific details of the surgical procedure, how well the patient tolerated the procedure, and any complications that occurred
- 3. A signed document by the patient or legal guardian that explains the purpose, risks, and benefits of a procedure and serves as proof that the patient was properly informed before undergoing a procedure
- 4. A record that includes a current head-to-toe assessment of the patient’s physical condition
- 5. Electronic record of health-related information for an individual