Final answer:
In a patient's hospital chart, the Admission Sheet provides initial diagnostic information, while the Social Service Record includes psychosocial history. ICD codes associated with tests and procedures can be found in billing records and laboratory results.
Step-by-step explanation:
When a patient is admitted to the hospital with a tentative medical diagnosis, and multiple diagnostic tests are performed, a nurse can find important information about these tests scattered throughout the patient's medical record. However, specific details regarding the admission and diagnostic results can be located in particular sections of the chart.
The Admission Sheet is typically the first place to look for initial diagnostic information, as it includes the patient's presenting symptoms, the tentative medical diagnosis provided by the physician upon admission, and any initial orders for diagnostic tests. The admission sheet serves as a summary of the patient's initial status.
The Social Service Record may not directly contain results of diagnostic tests, but it includes vital information about the patient's psychosocial history, support system, and potential discharge planning needs which may be relevant to the patient's overall care plan.
In addition to this, health records will also include details of any checks conducted pre- or post-procedure to ensure all medical protocols are followed, such as confirming the correct labeling of specimens and ensuring all equipment issues are addressed.
It is also standard practice for medical professionals to use International Classification of Diseases (ICD codes) when ordering laboratory tests, documenting procedures, and processing insurance claims. These codes can typically be found in the patient's billing records or the laboratory results section.