Lecture 5: Medical Records

Set of practices, ethics, and behaviors that members of particular professional group must adhere to. These are frequently agreed to by a governing a governing body that represents the interests of the group.

 

Its main purpose is to direct and maintain safe and clinically competent nursing practice.

Legal document providing a chronicle of a patient's medical history and care. Includes variety of "notes" entered over time by health care professionals.

In writing medical report, we only have two participants:

patient &/or healthcare provider (with authorization)

In writing a medical report, either it is the healthcare provider or the patient who is writing. Make sure the signature and date are written because these are the most valuable notes to justify the legitimacy of the medical report.

 

 

 

One of the first important components you can find in medical records.

Medical records needs to have this to help identify who the history belongs to. 

 

ex:

Social security number, marital status, date of birth, name.

It is considered for everyone, even those who have never been to doctor and hospital. This is used as a baseline to determine the applicable treatment for the patient.

 

Includes:

Allergies, Treatments, Medical Care, Present and past diagnosis

This information may be gathered through patient testimony or through prescriptions from past doctors already on file.

 

Medicines a patient is ingesting need to be documented in their medical record. Wether they have tried herbal remedies, illegal substances, OTC medication, everything should be included.

 

 

It can play an important role in their health. Many health concerns can be genetic, making them important to add to the file.

It is another vital part of the patient's medical record. It encompasses all treatments they have ever undergone and their results.

 

Includes:

(1) Chief complaints           

(2) History of illness       

(3) Vital signs                   

(4) Physical examination  

(5) Surgical history            

(6) Obstretic history

(7) Medical allergies

(8) Family history

(9) Immunization history

(10) Diet, alcohol intake, exercise, drug use, smoking, etc.

(11) Developmental history.

A crucial documents to outline directions by the patient regarding what they want or do not want in case they cannot communicate with their medical care (autonomy)

 

Includes:

DNR (do not resuscitate order, and their will)

Different _____ that the patient has received are all added to the record. It contains information or report related to cells, tissues, body fluids.

 

Other reports such as X-ray and imaging tests produced through mammograms, scans, x-rays, ultrasounds

Patients should be able to make informed decisions about their care; thus the physician should let the patient know all important information about all medical procedures.

 

Information includes:

(1) Diagnosis

(2) Recovery Chances

(3) Recommended Treatments

(4) Benefits and Risks of Treatment

(5) Risk if the Treatment is not taken

(6) Success probability if Treatment is taken

(7) Length of recovery time and challenges

These are made by physicians if changes or new information come up during the course of treatment.

 

Some information included within these are:

(1) Vital Signs

(2) Food intake

(3) Sudden changes taking place

(4) Observation of the mental and physical condition of the patient

(5) Bowel & bladder functions

Also an important part of patient's medical records.

 

Includes:

(1) Subscriber Namer

(2) Policy Number

(3) Name, phone number, and address of Insurance payer

(4) Relationship of patient to one insured

(5) Phone number, address, and name of the responsible party

(6) Occupation, employer phone number, and employer of the responsible party

 

The following should be written on the medical folder:

(select three answers below)

In many healthcare settings, medical professionals under Radiology Department are not responsible of compiling and labeling of medical records. They will just typically focus on imaging and diagnostic procedures.

The MRN (medical record number) should be issued in straight numerical order from the NUMBER REGISTER starting with the number 1.

 

UID Number may change but OPD Visit number/IPD is permanent.