Question

determine a standardized health record format for a specific healthcare setting.

Answer 1

The Health Record is a systematic collection of health information. It is a complication of patient’s facts, allergies, and health data of a patient. Health history includes past and present illness, and treatments. Health records must keep in order that quality reviews may evaluate the adequacy and appropriates of care. Example: consider a health record in the physician's office. The main components of a health record consist of a defined database, the complete problem lists, plans, and progress notes. The defined databases consist of chief complaint, patient profile, history, consultation details, laboratory examinations, and radiology findings. The plans in the record are written for the future diagnostic procedure, therapy, and client education. The progress notes are written in the subjective, objective, assessment, plan format.

Subjective: it includes past history, presenting complaints

Objective: this information is derived from the physical examination and diagnostic test reports, laboratory reports, etc.

Assessment: it includes the provisional diagnosis, results of the consultation, and the final diagnosis are listed under assessment.

Plan: plans are made for client education and it comprises of future diagnosis studies, assessment, etc.