Hcs120
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Patients Health Data and Technology
HCS 120
December 21, 2015
Patients Health Data and Technology
Healthcare professionals that provide care to a patient, document all health care information in a medical record. Beginning with an approximate twenty years ago, medical information acquired from a patient to input to their personal file was pretty standard and still is today. Believe that it is possible to accumulate at least a couple of feet tall worth of documentation after just a couple of visits, depending on your illness or ailments. The information included in a medical record varies but, the standard information includes an account of events throughout the patients’ health history and present life. The doctors’ office does not require as much information as a hospital would. The reason for the excess hospital information is because the patient stay at a hospital is considered an in-patient stay and many healthcare professional staff will be looking after the patient. The staff looking after the patient are nurses and doctors and every shift of nurses and doctors must document the patients’ health during their stay. Although information included in a medical record may vary, hospitals require more information to their medical records which are located in hospital database. This documentation from hospitalized patients’ not only include demographics but Admit History and Physical Examination which is also known as H&P. There is also a section for an Operative Report for patients entering and exiting surgery or minor surgeries that involve a detailed summary in its’ own category. In addition to the operative report, there is a discharge summary that may include a treatment plan that the doctor and patient have discussed prior to discharge. Among the admit history and physical examination, operative report, and discharge summary there are written orders, nurses notes, and other important departments that must contribute to medical records including, but...
HCS 120
December 21, 2015
Patients Health Data and Technology
Healthcare professionals that provide care to a patient, document all health care information in a medical record. Beginning with an approximate twenty years ago, medical information acquired from a patient to input to their personal file was pretty standard and still is today. Believe that it is possible to accumulate at least a couple of feet tall worth of documentation after just a couple of visits, depending on your illness or ailments. The information included in a medical record varies but, the standard information includes an account of events throughout the patients’ health history and present life. The doctors’ office does not require as much information as a hospital would. The reason for the excess hospital information is because the patient stay at a hospital is considered an in-patient stay and many healthcare professional staff will be looking after the patient. The staff looking after the patient are nurses and doctors and every shift of nurses and doctors must document the patients’ health during their stay. Although information included in a medical record may vary, hospitals require more information to their medical records which are located in hospital database. This documentation from hospitalized patients’ not only include demographics but Admit History and Physical Examination which is also known as H&P. There is also a section for an Operative Report for patients entering and exiting surgery or minor surgeries that involve a detailed summary in its’ own category. In addition to the operative report, there is a discharge summary that may include a treatment plan that the doctor and patient have discussed prior to discharge. Among the admit history and physical examination, operative report, and discharge summary there are written orders, nurses notes, and other important departments that must contribute to medical records including, but...