What is put in a patients medical chart the hospital?

Patient's name and demographic information: This includes the patient's full legal name, date of birth, gender, primary language, contact information, and next of kin.

Medical history: This includes a detailed account of the patient's past medical conditions, surgeries, hospitalizations, allergies, and medications.

Physical examination findings: This includes a description of the patient's vital signs, general appearance, skin, head and neck, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and neurological systems.

Laboratory and imaging studies: This includes a list of the laboratory tests and imaging studies that have been ordered for the patient, along with the results.

Progress notes: These are written by the physician or other healthcare provider each time they see the patient. They include a summary of the patient's condition, the plan of care, and any changes in the patient's status.

Consultation reports: These are written by specialists who have been consulted to provide their expertise on the patient's case. They include a summary of the specialist's findings and recommendations.

Discharge summary: This is a summary of the patient's hospital stay, including the diagnosis, treatment, and prognosis. It is written by the physician or other healthcare provider who is responsible for the patient's care.

Other documents: In addition to the above, the patient's medical chart may also include other documents, such as the patient's advance directives, insurance information, and financial records.