The patient health record is always started out the same way. A demographic sheet is the first item that appears in the patient chart. The demographics are the primary way the healthcare entity manages all other interactions with the person. This sheet has the medical record number, name, address, phone number insurance information and next of kin information. It is often the first item requested when a patient is transferred to another facility. Information is updated at every visit to the healthcare facility. This information is used to ensure that the correct information is going into the correct patient chart.
Documentation in a patient chart is done by almost every person on the patient care team. Documentation includes a history and physical completed by the provider. This will give the provider the basis for decisions to be made and orders to be considered. This document will be used by the nursing staff to obtain information regarding medications and past medical history. If a specialist is consulted, that person will have a baseline record. Other members of the health team will also use the H&P for treatment purposes, such as dieticians, physical and respiratory therapists among others. The H&P is almost always dictated.
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...uramine was a drug used in combination with phentermine to produce weight loss. This combination did work, but the side effects of Fenfluramine had not been fully appreciated until later. Fenfluramine caused pulmonary hypertension and heart valve problems. This could only have been discovered as physicians and the manufacturer studied medical records and proved a link between the medications and the undesired side effect (Hiiti).
The medical record is not just used while a person is visiting the office or hospital, only to await the next visit. It is a valuable tool to help in the decision making processes of the healthcare organization, researchers, and scientists. The health care record in the age of the electronic record could be and will be used for more analytics, but care must be taken to safeguard the personal information of the individual.
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