Medical Records

This includes:

1. health history of patient/client 
2. a report of the findings on examination 
3. signs and symptoms 
4. observation records 
5. progress notes 
6. discharge summary 
7. instruction to be followed at home 

The following items are included in patient's/client's record:

1. identification data 
2. complaint, reason for seeking medical aid 
3. present illness 
4. past history 
5. family history - 
6. physical examination 
7. special examinations 
8. provisional and final diagnosis 
9. treatment medical/surgical 
10. pathologist's report 
11. Maintenance of Records 
12. progress notes 
13. condition on discharge 
14. follow-up records 
15. autopsy findings 
16. day to day nurses notes