Management of Patient Records

The most significant health treatment database for patients is their health records. When nurses, doctors, and other staff routinely record health data, it demonstrates that effective health monitoring, treatment, and planning is taking place. These health data also serve as the foundation for determining an individual’s rights, such as legal and civil transactions, as well as privacy rights under HIPPA. This assignment will examine many types that comprise a patient’s health record.

There are two types of health records: paper and electronic. In some cases, they can exist in both forms, which is known as a hybrid record. There are many different forms which make up a medical record. For instance the medical history is included in a health record to assist in proper care of a patient. The history contains: patients’ demographics, illness history, family history, social history, allergies, medication history, review of systems and physical examination (Linda & Kimberly 2015). Other forms which are included in the medical record include: diagnostic test results, laboratory test results, problem list, clinical notes, and treatment notes. All these are briefly explained below.

Patient demographics: this section consists of patient’s name, date of birth, address, phone number, race, attending physician name, gender, and marital status. The patient’s insurance, name of pharmacy and religious preference information may also be included in this section.

Present illness history: this is recorded chronologically by also describing the symptoms of the patient in details. Information regarding past treatment and test results previously is also included here.

Past medical history: this consists of the past and present medical conditions. Included here also is the surgical history (Linda & Kimberly 2015). Also, a previous hospitalization, obstetrical history and trauma history is also recorded.

Family history: this includes the patient’s parents, siblings, and children information. It includes the age, chronic condition presence, and status i.e. dead or alive.

Social history: This comprises the lifestyle of the patient and personal characteristics like use of tobacco, alcohol, and illicit use of drugs, all of which documented with amount, frequency, and type and use duration. Others information included here is the patient’s dietary habits, caffeine use, and exercise routine as well as education, marital status, occupation, children, sexual behaviors, living conditions and military history.

Allergies: this is presented in a different form. This is a representation of the allergic reactions to a patient. This includes foods, stings, vaccines, and contrast media.

Physical examination: this is a review of the state of all organ systems done by the practitioners to the patient. This is carried out through touching and observing the patient.

Diagnostic tests results: this includes results from ultrasounds, electrocardiograms, computed tomography (CT) scans, x-rays, magnetic resonance imaging (MRI) scans, and echocardiogram and so on. They are often available in a computer system.

Problem list: this includes a list of prioritized needs of a patient that require to be attended by a practitioner. This is listed in an order of priority, where the most prevalent symptom is listed first and attended to first.

Clinical motes: These are daily progress notes of a patient recorded by numerous practitioners within the hospital unit. Also, other specialists like the cardiologists and cardiologists also document findings of their own on a daily progress note (NSW Government Health, 2012).

Treatment notes: these are often used in inpatient settings. They include treatment notes, surgical procedures documentation, medical administration records and documentation of services like physical therapy, radiation therapy, occupation therapy, nutrition and respiratory therapy.

All these medical records serve the following purposes (NSW Government Health, 2012):

Patient care continuity

Communication purposes

Patient care evaluation

Statistical purposes

Research and education purposes

Historical purposes

Medico-legal purposes

References

Linda M.S., & Kimberly A.P., (2O15). The Medical Records

NSW Government Health, (2012). Healthcare Records-Documentation and Management. Ministry Of Health, NSW