StudentShare
Contact Us
Sign In / Sign Up for FREE
Search
Go to advanced search...
Free

Importance of Health Records - Essay Example

Cite this document
Summary
This essay "Importance of Health Records" mentions that a medical record is a taxonomic certification of a patient’s individual anamnesis and aid. The name medical record is applicable for both the physical folder for every single patient and for the entire health history of every single patient…
Download full paper File format: .doc, available for editing
GRAB THE BEST PAPER93.3% of users find it useful
Importance of Health Records
Read Text Preview

Extract of sample "Importance of Health Records"

A medical record is a taxonomic certification of a patient’s individual anamnesis and aid. The medical record is applicable for both the physical folder for each single patient and for the body of information that constitutes the entire health history of every single patient. Medical records are highly confidential documents and there are several honorable and effectual issues regarding them like the degree of approach of third party and proper storage and administration. Though medical records are conventionally collected and laid in by health care suppliers, personal medical records held by the patients themselves have turned more common currently. Purpose The data comprised in the health record permit the health care suppliers to render continuance of care to each individual. The health record also helps as a foundation for devising patient care, recording the dialogue between the healthcare supplier and any other medical professional leading to the patient’s aid helping in defending the legal concern of the patient and the health care suppliers trustworthy for the care of the patient and recording the aid and services rendered to the patient. Moreover the health record may serve as a study material for medical students, occupant physician, to render information for inner hospital inspecting and quality sureness and to render information for medical research. Personal medical records mix many of the above mentioned features with movability, hence granting a patient to share health records across suppliers and health care schemes. Keyword: health records Importance of Health Records Contents Fundamentally a patient’s personal health record shall identify the patient and shall comprise the data received with a certain case and shall pertain to preceding cases with the same patient. In fact the subjects are scripted by the medical suppliers, and the patient has no idea concerning what is written or not written there, whether a reported item is right or not. This bears many aftermaths if health care providers’ conduct would be questioned, as the patient doesn’t have the papers to tell the truth, though the medical faculty would be able to insist that the truth is what is entered in the medical record. Format Conventionally, medical records were scripted on papers and placed in folders. These folders are particularly classified into useful sections, with new data summed up to each segment in chronological order as the patient faces new medical issues. Alive records are commonly put up at the clinical site, but older ones [records of deceased] are usually placed in different facilities. The arrival of electronic medical records has modified the format of medical records as well as made them more easily retrievable. The usage of a single written account mode medical record, where records are placed on the basis of name and disease type originated at the Mayo Clinic out of a hope to simplify patient trailing and to permit for medical research. Medical History It is a long record of what has occurred to the patient after birth. It accounts diseases, minor and major sicknesses as well as growth reports. It provides the practitioner an idea about what occurred to the patient in the past. As such, it may frequently provide hints to recent sickness states. Following are the subsets included in it. Surgical History The surgical history is an account of surgery did for the patient. It consists of operation dates, operative reports or the elaborated story of what the surgeon did. Obstetric History This lists prior pregnancies and their consequences. It also comprises any ramifications of these pregnancies. Medications and Medical Allergies The medical record may consist of brief report of the patient’s recent and former medicaments and any medical allergies as well. Family History It lists the health condition of immediate relatives and their reason of death as well. It may also show illness common in the family or found in just one sex or the other. It may also have a pedigree chart. It is a precious asset in determining some consequences for the patient. Social History This is an account of human interactions. It describes the kinships of the patient, his vocations and trainings, school life and religious life. It would be useful for the physician to understand what kinds of community backup the patient might require during a major sickness. It may explicate the conduct of the patient regarding sickness or loss. It may also provide hints regarding the reason of an illness. Habits Several habits which affect wellness, such as drinking, smoking, exercise and diet are recorded as component of the social history. This segment may also contain more personal details such as sexual habits and sexual preference. Immunization History This includes the account of vaccination. Any blood test to determine immunity will also be contained in this section. Growth Chart and Developmental History For the sake of children and teenagers, graphs recording growth when compared to other children of the same age is comprised such that health care suppliers can trace the child’s growth over time. Several diseases and social tensions can impact growth and long graphing and can hence render a clue to rudimentary illness. In addition to this a child’s conduct as compared to other children of same age is authenticated within the medical record mostly for the same reasons as growth. Medical Encounters Within the health record, soul medical confrontations are noted by distinct rundowns of a patient’s medical account by a physician, nurse practitioner or physician assistant and can take various forms. Documents regarding admission or consultation by a specialist always take a thorough form, particularizing the totality of former health and health care. Everyday visits by a supplier known to the patient still may take a smaller form such as the problem oriented medical record which contains a trouble list of diagnoses or a SOAP method of certification for every visit. Each confrontation will mostly contain the aspect given below. Chief Complaint This is the trouble that has led the patient to see the doctor. Data on the nature and continuance of the problem will be researched. History of the Present Illness An elaborated research of the indications the patient is feeling which have induced the patient to look for medical care. Physical Examination It is the registering of observations of the sick person. This comprises the critical signs, muscular strength and testing of the various organ systems, particularly those which might be right away responsible for the consequences the patient is going through. Assessment and Plan It is a written rundown of that which are responsible for the patients recent set of symptoms. The plan reports the awaited course of action to address the consequences. Orders and Prescriptions Written observations by medical suppliers are contained within the medical record. These point the directions to other members of the health care team by the main providers. Progress Notes When a patient is admitted to the hospital, daily informs are registered into the medical record entering clinical changes, new data, etc. These always take the form of a SOAP note and are recorded by all the members of health care team such as respiratory therapists, clinical pharmacists, dietitians, physical therapists, nurses and doctors. They are placed in chronological order and report the order of events leading to the recent condition of health. References Health record. Retrieved from, www.ncbi.nlm.nih.gov AHIMA e-HIMTM Work Group: Guidelines for EHR Documentation Practice. "Guidelines for EHR Documentation to Prevent Fraud." Journal of AHIMA 78, no.1 (January 2007): 65-68.http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_033097.hcsp?dDocName=bok1_033 Read More
Cite this document
  • APA
  • MLA
  • CHICAGO
(“Importance of Health Records Essay Example | Topics and Well Written Essays - 1000 words”, n.d.)
Importance of Health Records Essay Example | Topics and Well Written Essays - 1000 words. Retrieved from https://studentshare.org/health-sciences-medicine/1571264-essay-listing-and-comparing-health-record-documentation-requirements-for-outpatient-and-inpatient-provider-documentation
(Importance of Health Records Essay Example | Topics and Well Written Essays - 1000 Words)
Importance of Health Records Essay Example | Topics and Well Written Essays - 1000 Words. https://studentshare.org/health-sciences-medicine/1571264-essay-listing-and-comparing-health-record-documentation-requirements-for-outpatient-and-inpatient-provider-documentation.
“Importance of Health Records Essay Example | Topics and Well Written Essays - 1000 Words”, n.d. https://studentshare.org/health-sciences-medicine/1571264-essay-listing-and-comparing-health-record-documentation-requirements-for-outpatient-and-inpatient-provider-documentation.
  • Cited: 3 times

CHECK THESE SAMPLES OF Importance of Health Records

Good Record Keeping Helps to Protect the Welfare of Patients

An example of how and where this system of integrated record keeping works are the personal child health records.... The importance of record keeping in patient care process is beyond discussion.... According to the Guidelines to records and Record Keeping, 'record keeping is a fundamental part of nursing and midwifery practice' (2002, p.... The way the medical records are being kept and saved is a reflection of a practitioner's professional level and the standards of medical care....
16 Pages (4000 words) Essay

Keeping Nursing Records

Record keeping refers to an automated or manual system responsible for collecting, organizing, and categorizing records to facilitate their preservation, use, retrieval and disposition.... They include; records,… records entails the information created or received for action, people-entails the records contacts, records staff and the records Liaison Officers in charge with over seeing the records management program....
5 Pages (1250 words) Essay

The Importance of Quality in Health Records

Indeed, accurate and complete clinical documentation of health records define the quality of health records.... A quality audit of health records refers to the process of conducting internal or external reviews of all the tools, policies, procedures, and techniques used in healthcare institutions to ensure that the health records are up-to-date, accurate, efficient (Holmboe, n.... health records can be on either paper or electronic with the Electronic Health… cords (EHRs) being favored in the modern world where they significantly improve the quality and safety of health care in the United States (Agency for Healthcare Research and Quality, 2013)....
2 Pages (500 words) Essay

WHS Management Systems

This research is being carried out to evaluate and present the development and implementation of a new form of work health and safety (WHS) in Australian hardware.... It is important for the hardware to comply with WHS which is done by improvising introduction of applicable work health and safety practices within the firm.... The WHS Act, 2012 was stipulated with the main aim of safeguarding safety and health measures and also to ensure that they are duly managed and carried out....
4 Pages (1000 words) Assignment

Best Practices in Electronic Health Records

The author of the essay under the title "Best Practices in Electronic health records" states that electronic health records (EHR) are increasingly being used within health care organizations but this poses several challenges.... Hence it becomes necessary to understand the trade-off between the investment in EHR and maintaining paper records.... This has been studied through an investigation into the practices of one health service provider that uses EHR and another that continues with paper records – namely – Mercy Medical Center and Advocate Health Center....
8 Pages (2000 words) Essay

Solving Explosion of Information in Electronic Media Records

edia records contain private information hence the need to mitigate the possible risks, which can affect their reliability and privacy.... lectronic Heath Record and Electronic Medical record contains health information for an individual or a population.... This paper as about electronic media record is a long-term storage media that considers and incorporates all the essential features in data storage like accessibility, durability, trustworthy and converter ability....
8 Pages (2000 words) Literature review

Several Medical Record Formats at the Healthy Facility Record

he following are the both physical and technical measures which should used to secure health records; there should be facility access controls such as alarms and locks, there should be proper policies in the workstation to make sure that there is proper access and use workstations, workstation security measures, such as computer privacy filters and cable locks, there should be a good plan on how to restore lost data.... he following are the physical/ technical measures which are used to secure HIM department; both internal and external departments should be taught the importance of computer security, one should ensure that all other staffs take seriously security he or she does, ensure that all the information in the system components are catalogued because there are no two medical practices which have the same information, one should be ready for the disaster even before it has struck this means there should be an alternative method of backing up all the information in the system....
6 Pages (1500 words) Assignment

Information Security of Health Record Systems

These include proper human resource development in healthcare records education, service delivery and information of health records security.... Availability of health records refers to easy accessibility and usability of health records upon demand by an authorized person.... Therefore, sound and reliable health records systems are required in achieving proper decision making processes.... Integrity on the other hand makes reference to the fact that health records should not be destroyed in an unauthorised manner....
8 Pages (2000 words) Assignment
sponsored ads
We use cookies to create the best experience for you. Keep on browsing if you are OK with that, or find out how to manage cookies.
Contact Us