Question

2. What you would find in a patient's medical record.

Answer 1

MEDICAL RECORDS

A medical record is the complete information of patient's clinical data.A medical record comprises of various medical data which can be used for continuation of care and for future references.A medical record is systematic documentation pf a patient's health and illness history.The contents of medical records are entered notes over the time by the health professionals.

Medical records have traditional way of paper pen chart and more advanced method online data storage and other softwares The medical record will have medical history like vital signs,medications,demographics,treatment plans and expected outcome,progress notes,special consideration,problems,immunization dates,different test results etc.

USES OF MEDICAL RECORDS

1. For references
2. To know the patients medical history and to know the treatment provided.
3. Administration issues
4. Future studies( research)
5. Legal issues.etc.

THERE ARE MAINLY TWO TYPES OF MEDICAL RECORDS:Paper based and paper less.