Discuss how the documentation in the health record supports the patient’s diagnosis.

Expert Solution

Maintaining of health records is a very important part of documentation. The documentor always follows - SOAP - subjective, objective assesment and plan. This leads to consistent, reliable and comprehensive documents.

The subjective information is gathered from patient and the attenders. Chief complaints, signs and symptoms, problems in daily living, medically relevant history are recorded under this.

The objective information is gathered by thorough physical examination of the patient. All the systems are examined under this. Then all the findings are noted carefully. All the positive and negative findings are documnented.

After taking subjective and objective information, assesment of the information is done to reach a conclusion. All the information collected is carefully analyzed to check what the disease or problem could be and what is not. The documentation helps healthcare personal to know about all the signs, symptoms, medical history relevant to some diseases which can help make a diagnosis. After careful analysis of the information collected a diagnosis can be made. Documentation helps in omiting the errors made in diagnosis. It helps in consistent, adequate and comprehensive diagnosis.

After the diagnosis is made, plan of treatment is charted which is specifically goal oriented. Measures to help patient are also listed.

Nightingale answered 2 years ago

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