Question

What information will the health care team include in documenting the procedure for the patient's medical record?

Answer 1

Clinical record keeping is intergral to good professional practice and the delivery of quality health care

A medical record should include any and all summations revelant to the patient's care such as,

Demographics - eg,race ,age,religion ,occupation ,contact information

Chief compliant

History of present illness

Physical examination[vital signs,organ system examination]

Assessment and plan[diagnosis and treatment]

Docter orders and prescriptions

Progress note

Nurses notes

Test results [eg imaging results ,pathology results,specialized testing

Medical encounters -eg, hospital admissions,specialistconsultations ,routine checkups

Surgical history - for example operation dates,operation reports, operation narratives

Obstetric history -eg,pregnancies ,any complication ,pregnancy outcomes

Family history -eg,immediate family member health status ,cause of death,common family diseases

Social history -eg, community support ,close relationships ,past and current occupation

Habits-eg,smoking ,alcohol consumption,exercise ,diet,sexual history

Immunization record-eg,vaccinations ,immunoglobulin test

Developmental history -eg,growth chart ,motor development ,cognitive /intellectual development ,social -emotional development ,language development