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

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

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Expert Solution

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

Nightingale answered 1 year ago

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