Question

Technology in health care continues to advance, yet there is still a time and place for paper documentation. One of the most common paper documents is a patient intake form. For this week’s assignment, you will examine the functionality of this type of documentation, and offer improvements.

For this assignment, you will create a patient registration form. You may use an existing form as a guide, and make revisions as necessary when creating your document.

• Your form should be one page in length, formatted in a clean, professional manner.
• Key data that will be used in EMR reporting should be in boldface text.
• On a separate page, briefly summarize why each of the key data points are important for reporting purposes.
• A minimum of three references, in APA format, should be included on a separate page. Sources may include forms used to create your document.

Please review the rubric to ensure that your assignment meets criteria.

Submit:

• Patient Registration Form
• Document with the summary of the data points

Answer 1

Time and date of admission

Personal data:

Name: Sex : Male /Female/transgender

Age : Occupation:

Marital status: Nationality:

Religion : Income:

Attending physcian:

Presenting complaints:

Duration of the complaints

Past medical history:

List of medication:

General Examination

Height: Weight:

Temperature:

Pulse rate :

Respiratory rate :

Blood pressure:

Pallor/ cyanosis/ clubbing / lymphadenopathy

Pedal edema

Pupil :

Systemic Examination

CVS: S1S2 present, murmur+/-

RS: look for air entry, chest movement, added sounds

GIT: distension, bowel sounds+/-

CNS:neurological defeceit

Diagnosis

Lab investigation:

Personal data is to know and understand the person in details, which place he is from, what cultural backgrounds he is having, if he can afford the treatment or not

Date of admission: to know when the patient is under your treatment

General examination: gives a first hand information of which system is involved

Check on the vitals

Systemic examination : to find out particular system problem

And finally come to a diagnosis

Lab Investigation: give as which all investigation send and what further management is to be done