lanerd.blogg.se - What is the purposes of medical records

Nurse’s notes include documentation separate from the physician including: Record of findings from radiology testing. Lab Reports: Record of findings from lab testing. Prescriptions for medications and medical supplies or equipment for the patients home use.Ĭonsults: Findings opinions from consulting physicians. Physician’s orders for the patient to receive testing, procedures or surgery including directions to other members of the treatment team. Sudden changes in the patient’s condition.Observations of the patient’s physical and mental condition.Some of the information included in progress notes includes: They are written by all members of the patient’s treatment team.

Progress notes include new information and changes during patient treatment. Habits such as exercise, diet, alcohol intake, smoking, and drug use/abuse.Signature of the person authorized to release the information.

The name of the person or organization that the information is to disclosed.The name of the person or organization authorized to disclose the information.A description of the information to be used or disclosed.Identity verification such as a driver’s license.Assignment of benefits: the patient or guarantor authorizes their health insurance company to make payments directly to the physician, medical practice or hospital for the treatment received.Ī valid authorization to release protected health information includes:.Probability of success if treatment is taken.Risks and benefits involved in treatment.Responsible party employer, occupation and employer phone numberĬonsent for treatment: For any course of treatment that is above routine medical procedures, the physician must disclose as much information as possible so the patient may make an informed decision about his/her care.Responsible party name, address and phone number.Insurance payer name, address and phone number.

Spouse Name and contact information in case of emergency contact.

Occupation and Employer name, address, and phone number.

Sex, Age, Birthday, and Race (Ethnicity).

Address and phone numbers (home and mobile).

With the advent of the electronic patient record, these sections may still be found but as tabs or menus within the electronic record. As printed reports were generated, they were moved to the correct tab. Medical records traditionally were kept in paper form, with tabs separating the sections. It usually contains the patient’s health information (PHI) which includes identification information, health history, medical examination findings and billing information. A medical record is a systematic documentation of a patient’s medical history and care.