Medical Patient Records

625 Words3 Pages
Medical patient records are organized domcuments created to obtain patient medical history and previous care. Medical records are personal documents stored by his or her health care provider. Each medical record has enough information to distinguish each patient . It contains their first and last name with gender and age.

Every patient's medical records are different some contain more information due to their medical history. If a patient has alot of problems and have been treated then their file would have more information . Certain records also contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology terms that any person in the medical field can read It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected..

The purpose of a medical record is for the health care provider to provide endless care to the individual patient. It serves a source for planning patient care and the services provided to that patient. Medical records begin from when the patient born. It contains diseases, illness and whatever the patient tells their physician about his or her past and present status. It also contains lab test results, medication that was ever prescribed. It also contains allergies, referrals ordered to other health care providers and plans for further care.

Medical patient history inlcude families history and the status of the family members death if known. It tells relationships of the patient, his or her career and schooling this helps the physician to know and explain behavior of a patient in relation to illness or loss. It contains different habbits such as smoking use , alcohol , diet and exercise. History of vaccination is included and blood test prooving immunity. If a patient is hospitalized there are daily updates that are entered in the medical record; it documents clinical changes and new information.
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