Clinical notes |
Discharge summaries |
A document that describes the outcome of a patient’s hospitalization, disposition, and provisions for follow-up care. |
26 |
Progress notes |
A document that describes a patient’s clinical status or achievements during the course of a hospitalization or over the course of outpatient care. |
15 |
Admission notes |
A document that describes a patient’s status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient’s care. |
9 |
Operative notes |
A document that describes the details of a surgery. |
5 |
Primary care notes |
A document that describes the details of an outpatient during a primary care. |
3 |
Diagnostic reports |
Radiology reports |
Results of radiological scans and X-ray images of various parts of the patient’s body and specific organs. |
43 |
Pathology reports |
Results of pathological examinations of tissue samples and tissues of organs removed during surgical procedures. |
22 |
Colonoscopy reports |
Results of a colonoscopy. |
4 |