CD Crohn's disease. Discharge Summary A summary dictated by your physician during or after the hospital stay, including any tests or operations performed, laboratory data, your condition on discharge, and plans for follow-up care. Doctor's orders sheets A record of the medications ordered for you by your physician. EENT Eye, ear, nose, and throat. ESR Erythrocyte sedimentation rate.
Final diagnosis is added upon discharge.
A record of your temperature, pulse, respiration, and blood pressure while in the hospital. History and physical examination Contains your complete medical history as told to the admitting resident, as well as results of physical examinations. IVP Intravenous pyelogram. KLS Kidney, liver, and spleen. Laboratory Reports Results of various tests.