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.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Medical records are the most basic of clinical tools (Pullen and Loudon 2006) and their main importance is to serve as a form of memoir or aid in client and patient support. Medical records therefore provides essential evidence of care provision, thereby enabling effective communication between health care professionals, members of the multidisciplinary team and all clinicians as a whole.
Today, you have more reason than ever to care about the privacy of your medical information. This information was once stored in locked file cabinets and on dusty shelves in the medical records department.
Medical facilities have to follow certain guidelines. They have to insure patient’s privacy in all areas. The medical facility has to protect the patient medical records and all healthcare information for the patient. If paper files are still in use at the medical facility, it should be stored, where it can be locked at close of business. Also, medical files should not be kept where individuals, other than those that need to use them, have access to them. Electronic medical records are being pushed for all facilities, large or small. The thought is less chance of someone having access that should not. There are firewalls, password use, encryption and other means of protecting electronic health records.
Paper based health record was considered as gold standard during the early period because it was the main source of patient’s health information, was easy to use and it requires just minimal skill. The patient health records were kept by their providers attached to the bed for the easy access of the documents for patient care. The paper records can be lost during storage affecting patient care, duplication of tests making it more expensive care, doubtful as any person can make an entry without signing the paper and most often it is hard to read. So with the growth of advancement in medicine and technology, paper based health record cannot handle which led to the implementation of electronic health record (EHR), which is in digital format, accessible at any time, convenient, accurate and complete information, reliable, improves productivity as well as reduce health care cost of the patient. It also provides better clinical decision making thus providing better outcomes in patient health, which is the goal of the
Once the general structure of history is established, one can begin asking about presenting complaint, past medical history, mental health followed by medications history. It is important to find out about over the counter medications and herbal remedies that the patient is currently taking. Family history is also a good tool in taking patient history. The patient social history should also be included along sexual history and occupational activities. The nurse needs to gather information about the other systems in the body that are not covered during the beginning of the assessment. This will reduce the chance to omit any important information.
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
According to the American Health Information Management Association, Health information is the data related to a person’s medical history, including symptoms, diagnoses, procedures, and outcomes. Health information records include patient histories, lab results, x-rays, clinical information, and notes. The data can be analyzed to see how a patient’s health might have changed. I took interest in Health Information Management when it was brought to my attention by a doctor. He told me that is a very interesting field and it is in high demand as they have more jobs than people to fill them. I went home, researched it and now here I am making my entry into the field.
Over the last several years, electronic medical records are becoming more prominent in health care facilities, replacing traditional written records. As many electronics are becoming more prevalent with the invention of numerous smartphones and tablet devices, it seems that making medical records available electronically would be appropriate for the evolving times. Even though they have been in use to some extent for many years, the “Health Information Technology for Economic and Clinical Health section of the American Recovery and Reinvestment Act has brought paperless documentation into the spotlight” (Eisenberg, 2010, p. 8). The systems of electronic medical records mainly consist of clinical note taking, prescription and medication documentation,
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006).
“The history-taking interview should be of high quality and must be accurately recorded” (Craig & Lloyd, p.48). It is important that while obtaining a thorough health history, that the patient is treated with dignity and that their privacy is respected. A complete history involves the collection of physical and psychosocial aspects of one’s health.
Although the technology is kept on advancing from day to day, there are some clinics that are still using old method in handling their records. Piles of files in registry counter sometimes make the place looks messy and it takes a large space to store all the records of their patients. Sometimes, they cannot find a record due to misplace and the records might be lost. Each time they want to retrieve the records, they have to find based on the series number which sometimes the file is placed not according to the series number. This process will take more time than it should be. There are some clinics that are already implementing an electronic medical record and it gives positive impacts to their record management. Other than reduce time in retrieval the records of patients, the system also help to manage all the records efficiently. Besides that, by using this kind of system, the use of large space can be reduced. Same goes to the cost, the organization (clinic) can save more in terms of stationary and they do not have to hire many workers to manage their records.
This is when the physician can learn the most about the patient’s personality and environmental influences. It is important for the doctor to be attentive and take good notes. The doctor explores in great detail the time of the ailments and the severity. The physician inquires about the patient’s past health and any family history that is of relevance. The physician then checks the accuracy of all the data and details collected to date and informs the patient of the next step in the process, the diagnosis.
Medical records as you can see are very important not just for the physician but also for the patient. Though out history they evolved into not just a record of observations to prove the physician right or to use it as a way of collecting payment but as a way to track a patient’s health and wellbeing. Medical records are very important and will continue to be very important in the days and years ahead.
A health history is a collection of information about a patient that can be used to better understand the chief complaint. Learn about information gathering tools, such as the patient interview, history of present illness and the review of systems. A health history is a collection of information from a patient that provides a picture of his or her current state of health. When a patient's health history is elicited properly, it supplies the medical professional with important facts that will assist in making a proper diagnosis and creating a beneficial treatment plan. In this lesson, we will learn about the elements needed to elicit a thorough patient health history.