Question

Post #1: Describe the types of information that will be found in a Medical Record at least one example of each by Wednesday HINT: Financial information would contain insurance plan information and other information necessary for billing.

Post #2: Describe how an EHR can be beneficial for meeting meaningful use by Sunday

Answer 1

1. Types of information

• Patient profile

Includes patients name, sex, birth date, marital status, address, phone number, insurance details, employer details, emergency contact numbers, etc

• Progress notes

Written by the physician containing the patient's condition, examination outcomes, an outline of test results, treatment suggestions, etc.

• medical history

It includes the past and the present history of all medical conditions experienced by the patient.

• Lab Investigations

Records of the diagnostic evaluations done on the patient and its results.

• Billing information

Insurance plans and bills by the various departments of the hospital according to the service offered to the patient.

• Discharge summary

A brief explanation of diagnosis, Date of the admission, care and treatment given, patient's present condition, lab investigations and its results, follow-up plan, and date of discharge.