Identification should include
- patient's demographic data
- physician's medical orders (e.g., medications, treatments, diagnostic tests)
- patient’s history
- physical examinations and/or procedures
- lab and diagnostic tests
- progress notes from the interdisciplinary healthcare team
- legal directives (e.g., advance directives, living wills, DNR orders).
Process/Skill Questions
- Where would the nurse document his or her patient care?
- Where in the chart is an X-ray report located?
- Where in the chart is a medication order located?
- Where in the chart are doctor’s orders located?
- Who is authorized to view an electronic medical record?
- What are advance directives, DNRs, and living wills?