Medical Records

medical records are chronological written account of a patients examination and treatment that includes the patients medical history and complaints, the atomic number 101s physical findings, the results of symptomatic tests and procedures, and medications and therapeutic procedures. (dictionary.com, 2011) Patient medical history includes family history and the post of the family members, death of a family member and cause, 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 habits such as smoking, alcohol use, diet, and exercise. History of vaccination is included and blood test-proving immunity. If a patient is hospitalized, there are daily updates that are entered in the medical record; it enumerations clinical changes and new information. There enter by members of the health team and are kept in chronological order leading to the current state of health.

Medical records can be electronically stored, traditionally handwritten, and even spokesperson recorded. Written medical records on paper should be in blue or black ink, and kept in folders divided into informative sections. Each provider should always document the military rating and results of every patients visit.



It is forbidden to pre-date or tooshiedate an entry. When an computer error is do in a health record entry, proper error correction procedures must be followed. To fix an error haulage a line through the entry. Make sure that the faulty information is still legible, Write error by the paradoxical entry and state the reason for the error in the allowance account or above the note if room, sign and date the entry, and document the correct information. If the error is in a narrative note, it may be necessary to enter the correct information on the next available line, documenting the current date and time and referring back to the incorrect entry. (AHIMA, 2004)
A patient can...If you want to get a full essay, order it on our website: Orderessay



If you want to get a full essay, wisit our page: write my essay .