Importance of Health Records - Essay Example

A medical record is a taxonomic certification of a patient’s individual anamnesis and aid. The medical record is applicable for both the physical folder for each single patient and for the body of information that constitutes the entire health history of every single patient. Medical records are highly confidential documents and there are several honorable and effectual issues regarding them like the degree of approach of third party and proper storage and administration. Though medical records are conventionally collected and laid in by health care suppliers, personal medical records held by the patients themselves have turned more common currently. Purpose The data comprised in the health record permit the health care suppliers to render continuance of care to each individual. The health record also helps as a foundation for devising patient care, recording the dialogue between the healthcare supplier and any other medical professional leading to the patient’s aid helping in defending the legal concern of the patient and the health care suppliers trustworthy for the care of the patient and recording the aid and services rendered to the patient. Moreover the health record may serve as a study material for medical students, occupant physician, to render information for inner hospital inspecting and quality sureness and to render information for medical research. Personal medical records mix many of the above mentioned features with movability, hence granting a patient to share health records across suppliers and health care schemes. Keyword: health records Importance of Health Records Contents Fundamentally a patient’s personal health record shall identify the patient and shall comprise the data received with a certain case and shall pertain to preceding cases with the same patient. In fact the subjects are scripted by the medical suppliers, and the patient has no idea concerning what is written or not written there, whether a reported item is right or not. This bears many aftermaths if health care providers’ conduct would be questioned, as the patient doesn’t have the papers to tell the truth, though the medical faculty would be able to insist that the truth is what is entered in the medical record. Format Conventionally, medical records were scripted on papers and placed in folders. These folders are particularly classified into useful sections, with new data summed up to each segment in chronological order as the patient faces new medical issues. Alive records are commonly put up at the clinical site, but older ones [records of deceased] are usually placed in different facilities. The arrival of electronic medical records has modified the format of medical records as well as made them more easily retrievable. The usage of a single written account mode medical record, where records are placed on the basis of name and disease type originated at the Mayo Clinic out of a hope to simplify patient trailing and to permit for medical research. Medical History It is a long record of what has occurred to the patient after birth. It accounts diseases, minor and major sicknesses as well as growth reports. It provides the practitioner an idea about what occurred to the patient in the past. As such, it may frequently provide hints to recent sickness states. Following are the subsets included in it. Surgical History The surgical history is an account of surgery did for the patient. It consists of operation dates, operative reports or the elaborated story of what the surgeon did. Obstetric History This lists prior pregnancies and their consequences. It also comprises any ramifications of these pregnancies. Medications and Medical Allergies The medical record may consist of brief report of the patient’s recent and former medicaments and any medical allergies as well. Family History It lists the health condition of immediate relatives and their reason of death as well. It may also show illness common in the family or found in just one sex or the other. It may also have a pedigree chart. It is a precious asset in determining some consequences for the patient. Social History This is an account of human interactions. It describes the kinships of the patient, his vocations and trainings, school life and religious life. It would be useful for the physician to understand what kinds of community backup the patient might require during a major sickness. It may explicate the conduct of the patient regarding sickness or loss. It may also provide hints regarding the reason of an illness. Habits Several habits which affect wellness, such as drinking, smoking, exercise and diet are recorded as component of the social history. This segment may also contain more personal details such as sexual habits and sexual preference. Immunization History This includes the account of vaccination. Any blood test to determine immunity will also be contained in this section. Growth Chart and Developmental History For the sake of children and teenagers, graphs recording growth when compared to other children of the same age is comprised such that health care suppliers can trace the child’s growth over time. Several diseases and social tensions can impact growth and long graphing and can hence render a clue to rudimentary illness. In addition to this a child’s conduct as compared to other children of same age is authenticated within the medical record mostly for the same reasons as growth. Medical Encounters Within the health record, soul medical confrontations are noted by distinct rundowns of a patient’s medical account by a physician, nurse practitioner or physician assistant and can take various forms. Documents regarding admission or consultation by a specialist always take a thorough form, particularizing the totality of former health and health care. Everyday visits by a supplier known to the patient still may take a smaller form such as the problem oriented medical record which contains a trouble list of diagnoses or a SOAP method of certification for every visit. Each confrontation will mostly contain the aspect given below. Chief Complaint This is the trouble that has led the patient to see the doctor. Data on the nature and continuance of the problem will be researched. History of the Present Illness An elaborated research of the indications the patient is feeling which have induced the patient to look for medical care. Physical Examination It is the registering of observations of the sick person. This comprises the critical signs, muscular strength and testing of the various organ systems, particularly those which might be right away responsible for the consequences the patient is going through. Assessment and Plan It is a written rundown of that which are responsible for the patients recent set of symptoms. The plan reports the awaited course of action to address the consequences. Orders and Prescriptions Written observations by medical suppliers are contained within the medical record. These point the directions to other members of the health care team by the main providers. Progress Notes When a patient is admitted to the hospital, daily informs are registered into the medical record entering clinical changes, new data, etc. These always take the form of a SOAP note and are recorded by all the members of health care team such as respiratory therapists, clinical pharmacists, dietitians, physical therapists, nurses and doctors. They are placed in chronological order and report the order of events leading to the recent condition of health. References Health record. Retrieved from, www.ncbi.nlm.nih.gov AHIMA e-HIMTM Work Group: Guidelines for EHR Documentation Practice. "Guidelines for EHR Documentation to Prevent Fraud." Journal of AHIMA 78, no.1 (January 2007): 65-68.http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_033097.hcsp?dDocName=bok1_033 Read More