What is meant by medical record?
written information about a person’s health during their life to date.
What is in a patient’s medical record?
A medical chart is a complete record of a patient’s key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.
What is the purpose of the medical record?
The primary purpose of a medical record is to provide a complete and accurate description of the patient’s medical history. This includes medical conditions, diagnoses, the care and treatment you provide, and results of such treatments.
What are the types of medical record?
They are: 1. Patients clinical record 2. Individual staff records 3. Ward records 4.
What are the five purposes of the medical record?
Healthcare organizations maintain medical records for several key purposes:
- Patient Care. Patient records provide the documented basis for planning patient care and treatment.
- Communication.
- Legal documentation.
- Billing and reimbursement.
- Research and quality management.
What are two types of medical records?
The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.
What are 4 purposes of medical records?
What are 5 reasons medical records are kept?
List 5 reasons why medical records are kept.
- the health record helps the provider provide the best possible medical care for the patient.
- the health record also provides critical information for others.
- health records are kept as legal protection for those who provided care to the patient.
What are the three types of medical records?
01 Oct 6 different types of medical documents
- PIL. A PIL is a patient information leaflet you can find in any medicine bought at a pharmacy.
- Medical history record.
- Discharge Summary.
- Medical test.
- Mental Status Examination.
- Operative Report.
What are the five different types of medical records?
Terms in this set (20)
- EHR. Electronic health record that keeps basic profile information on a patient.
- Patient Data. Info that is provided by patient then updated as necessary.
- Medical History (Hx)
- Physical Examination (PE)
- Consent Form.
- Informed Consent Form.
- Physician’s Orders.
- Nurse’s Notes.
What are the 4 major purposes of the medical record?
A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.
What are the four 4 major purposes of the medical record?
Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.