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
Hypersensitivity to non-painful events may be part of pathology in fibromyalgia
New research shows that patients with fibromyalgia have hypersensitivity to...
medicalxpress.com
Marijuana users who feel low get high
Adolescents and young adults who smoke marijuana frequently may attempt...
medicalxpress.com
New knowledge of genes driving bladder cancer points to targeted treatments
The story of cancer care seems so simple: find the...
medicalxpress.com
Identifying a better message strategy for dissuading smokers: Add the positive
Which is more likely to convince a smoker to quit?...
medicalxpress.com
Working with aggressive children prevents some from becoming violent, criminal adults
Aggressive children are less likely to become violent criminals or...
medicalxpress.com
Schizophrenia not a single disease but multiple genetically distinct disorders
New research shows that schizophrenia isn't a single disease but...
medicalxpress.com
Vitamin E intake critical during 'the first 1,000 days'
Amid conflicting reports about the need for vitamin E and...
medicalxpress.com
Venezuela's newest shortage: breast implants
Venezuela's chronic shortages have begun to encroach on a cultural...
medicalxpress.com
Hundreds of Vietnamese drug addicts escape rehab
More than 400 Vietnamese drug addicts have escaped from a...
medicalxpress.com
Kids' poisonings linked to anti-addiction medicine
A federal study says an anti-addiction drug used to fight...
medicalxpress.com
Japan: More and more, a land of centenarians
Reaching the century mark remains a relative rarity for humans,...
medicalxpress.com
One care lapse can be fatal for heart attack patients
University of Leeds research has revealed that heart attack patients...
medicalxpress.com
Walking or cycling to work improves wellbeing, researchers find
Walking or cycling to work is better for people's mental...
medicalxpress.com
Breast screening for over 70s doesn't prompt sharp fall in advanced disease
Including much older women in a national breast cancer screening...
medicalxpress.com
Experts raise concern over unnecessary treatment of mild hypertension in low risk people
Lowering the drug threshold for high blood pressure has exposed...
medicalxpress.com
Cheaper alternative to licensed drug for treating eye disease has similar side-effects
Health policies which favour using ranibizumab for treating eye disease...
medicalxpress.com
TCT: Rx for Bifurcation Lesions -- Hold the Stenting
(MedPage Today) -- WASHINGTON ? When treating bifurcation lesions, ?less...
medpagetoday.com
TCT: When DES Fails, Try Another DES
WASHINGTON (MedPage Today) -- In-stent restenosis from a drug-eluting stent...
medpagetoday.com
TCT: Bioresorbable Scaffold Safe But Not Spectacular
WASHINGTON (MedPage Today) -- A year after implant, a everolimus-eluting...
medpagetoday.com
Week Ahead: TCT, Congress on VA, Flu Season
(MedPage Today) -- This week MedPage Today will cover a...
medpagetoday.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 +