Quantcast Components of a Medical Record - Health Care Ethics II

Share on Google+Share on FacebookShare on LinkedInShare on TwitterShare on DiggShare on Stumble Upon
Custom Search
 
  
 
e. Data Source. The medical record is a useful source of data for continuing
education programs and research. For example, the number of cases of spinal
meningitis reported in 1949, the symptoms reported, and the treatment provided can be
determined by a quick review of the medical records. Of course, all names would have
to be deleted from information extracted from the medical records to protect the
patients' privacy.
3-3.
CHARACTERISTICS OF A MEDICAL RECORD
Since medical records serve so many important purposes, they have to
constitute a complete, accurate, and up-to-date record of the patient's history, condition,
and treatment. The health care provider may, at times, view the record-keeping aspect
of the job as a nuisance; so much paperwork that detracts from the main mission--that
of caring for the patient. But, medical records serve so many important functions that
they cannot be taken lightly by the health care provider who is charged with making
accurate and timely entries. One adverse consequence of faulty record-keeping relates
to insurance reimbursement. If a hospital or physician fails to maintain complete and
accurate medical records reflecting the treatment rendered, it may not be possible to
obtain third-party reimbursement under MEDICARE, MEDICAID, and private insurance
coverage.
3-4.
COMPONENTS OF A MEDICAL RECORD
a. Admissions Record. The first part of the medical record, the admissions
record, is compiled when the patient is first admitted to the hospital. The admissions
record includes the patient's name, age, reason for admission, and any other pertinent
information on the patient's history.
b. The Clinical Record. The second part of the medical record is the patient's
clinical or treatment record. It should provide a continuing history of the treatment
provided and the patient's physical history. The exact nature of the complaint (the
reason for which the patient sought care) should be specified. There should be a
temperature chart, an admitting diagnosis and a subsequent diagnosis. (A patient
admitted for one complaint, might be revealed to have an entirely different diagnosis
after further testing or he or she might undergo a change in condition.) Consultations
should be included in the clinical record. The military "Consultation Sheet" should
accompany the patient as part of the patient's medical record when he or she is referred
to such places as orthopedics. Medical notes, medications, laboratory results, and x-
ray readings are additional components of clinical record. Surgical or delivery (birth)
records are also an important feature of the record. These should include anesthesia
reports and/or operative procedures and findings. Nursing notes, which list blood
pressure, temperature, and so forth, are another feature of the record. One-page
summaries of everything that has happened for the whole of the patient's hospital stay
are yet another important component of the record. The conditions of the patient at the
time of discharge and/or autopsy findings, if any, are also part of the record.
MD0067
3-3



Medical News
Make the Diagnosis: Anemia and Fatigue
(MedPage Today) -- A 75 year-old female presented with fatigue,...
medpagetoday.com
Medical marijuana support high ahead of Florida vote
Support for legalizing medical marijuana in Florida gathered steam ahead...
medicalxpress.com
Study shows new link between obesity in the young and the lowering of age of puberty
A new link has been identified between obesity in childhood...
medicalxpress.com
Researcher using next-generation sequencing to rapidly identify pathogens
He calls himself the bug hunter, but the target of...
medicalxpress.com
Smartphone app and specialised clinic for chronic fatigue patients
Sufferers of Chronic Fatigue Syndrome are set to benefit with...
medicalxpress.com
Potential 'universal' blood test for cancer discovered
Researchers from the University of Bradford, UK, have devised a...
medicalxpress.com
Motivation explains disconnect between testing and real-life functioning for seniors
A psychology researcher at North Carolina State University is proposing...
medicalxpress.com
Many people never grow out of their growing pains
A new research project from Aarhus University shows that many...
medicalxpress.com
Drug Combos Prove Potent as HCV Therapy (CME/CE)
(MedPage Today) -- The all-oral combination of two approved drugs...
medpagetoday.com
Children with disabilities benefit from classroom inclusion
The secret to boosting the language skills of preschoolers with...
medicalxpress.com
Burnout impacts transplant surgeons (w/ Video)
Despite saving thousands of lives yearly, nearly half of organ...
medicalxpress.com
Mutations from Mars: Researchers explain why genetic fertility problems can persist in a population
Some 15% of adults suffer from fertility problems, many of...
medicalxpress.com
Virus-killing molecules may need all their skills, including inflammation, to fight HIV infection
Using the body's natural virus killers to prevent and treat...
medicalxpress.com
Technology translation engine launches 'Organs-on-Chips' company
The Wyss Institute for Biologically Inspired Engineering at Harvard University...
medicalxpress.com
Morning Break: How One Doctor Got Rich, Myeloma Quiz
(MedPage Today) -- Health news and commentary from around the...
medpagetoday.com
Wearable device for the early detection of common diabetes-related neurological condition
A group of researchers in Taiwan has developed a new...
medicalxpress.com
Gender inequalities in health: A matter of policies
A new study of the European project SOPHIE has evaluated...
medicalxpress.com
Fist bumps more hygienic than handshakes, say scientists
Fist bumps are more hygienic than handshakes and drastically reduce...
medicalxpress.com
Could adding vegetables make a healthier mayonnaise?
Scientists are investigating if eating mayonnaise with added vegetables, in...
medicalxpress.com
Gene research targets scarring process
Scientists have identified three genes that may be the key...
medicalxpress.com
 


Privacy Statement - Copyright Information. - Contact Us

comments powered by Disqus

Integrated Publishing, Inc.
9438 US Hwy 19N #311 Port Richey, FL 34668

Phone For Parts Inquiries: (727) 755-3260
Google +