Medical Patient Records :: Electronic Medical Records

Medical persevering records argon create domcuments created to obtain patient medical exam narration and previous care. Medical records are personal documents stored by his or her health care offerr. Each medical record has enough information to distinguish each patient . It contains their archetypical and last name with gender and age. Every patients medical records are divergent some contain more information due to their medical history. If a patient has alot of problems and go for been treated then their file would have more information . Certain records withal contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology toll that any person in the medical field can scan It should be written in either black or lamentable ink. Each provider should always document the evaluation and results of every witness during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a splay written in a wrong patients file it should be date and signed by the person that is revising the file this shows proof that it was corrected..The pattern of a medical record is for the health care provider to provide endless care to the individual patient. It serves a source for planning patient care and the services provided to that patient. Medical records begin from when the patient born. It contains diseases, disease and whatever the patient tells their physician about his or her past and present status. It also contains lab test results, medication that was ever prescribed. It also contains allergies, referrals ordered to separate health care providers and plans for further care. Medical patient history inlcude families history and the status of the family members death if have it offn. It tells relationships of the patient, his or her career and schooling this helps the physician to know and explain behavior of a patient in relation to illness or loss. It contains different habbits such as smoking use , alcohol , diet and exercise. History of vaccination is included and blood test prooving immunity. If a patient is hospitalized there are daily updates that are entered in the medical record it documents clinical changes and new information.