What are the Key Components of a Complete Medical Record? A complete medical record will have a patient information form, medical history, physical examination, consent form, nursing records, doctor’s orders and progress reports, and more.
Medical practices need to maintain complete medical records with all the information about a patient’s health condition, medical history and other vital data. Accurate medical record data helps providers to take right treatment decisions. Today, most practitioners rely on professional medical transcription services to create and maintain accurate medical records. A patient’s medical history and care are systematically documented in a medical record. The record will also contain the patient’s health information (PHI), which includes identity data, medical examination results, and billing data. The amount, type, and degree of information included in medical records will vary from patient to patient. The valuable information in the
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medical record helps the physician understand the patient’s health and wellness, and provide the right care. Depending on the case, medical records may be useful in legal proceedings as well. Key Elements of a Medical Record 1. Patient Information Form 2. Medical History 3. Physical Examination 4. Consent Form 5. Form of Informed Consent 6. Doctor’s Orders 7. Nursing Records 8. Progress Reports from the Doctor 9. Reports on Consultations 10. Additional or other Reports 11. Diagnostic Procedures and Lab Results 12. Operative Report 13. Anesthesiology Report 14. Pathology Report 15. Discharge Summary Consistent, complete, comprehensive, and accurate information is crucial for proper care leading to optimal treatment outcomes. It is important for medical practices, hospitals and healthcare units to keep their medical records accurate and up-to-date. Utilize the services of a HIPAAcompliant medical transcription company can ensure quality medical record keeping and safeguard the privacy and security of all individually identifiable health information.
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