Include sentence in the Patient Medical Record effortlessly

Aug 6th, 2022
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How to Include sentence in the Patient Medical Record

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alright guys so this is were getting into chapter 12 which is called the health record and this section is broken up into two lectures as well so the first lecture in less than twelve point one chapter twelve point one what we want to talk about is introducing the patient records and the health record in general so throughout this lesson we need to be able to define spelling term mounts those terms listed in the vocab we need the name and discuss the two different types of patient records we need to state several reasons that accurate health records are important and differentiate between subjective and objective information in creating a patients health record and then explain who owns that health record as well well also distinguish between an EHR and an EMR and well do the following related to the legislation and EHRs will explain the a double RA which applies to the health care industry will define meaningful use and then well list three components of meaningful use in legisla

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A health record (also known as a medical record) is a written account of a persons health history. It includes medications, treatments, tests, immunizations, and notes from visits to a health care provider.
There are three types of medical records commonly used by patients and doctors: Personal health record (PHR) Electronic medical record (EMR) Electronic health record (EHR)
With the advent of the electronic patient record, these sections may still be found but as tabs or menus within the electronic record. Patient Demographics: Financial Information: Consent and Authorization Forms: Release of information: Treatment History: Progress Notes: Physicians Orders and Prescriptions:
The following is a list of items you should not include in the medical entry: Financial or health insurance information, Subjective opinions, Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.
Here are the ten components of a medical record, along with their descriptions: Identification Information. Medical History. Medication Information. Family History. Treatment History. Medical Directives. Lab results. Consent Forms.
medical test results (from lab tests, X-rays, etc.) medicines, including doses and how often the medicine is taken. allergies to medicines (both prescription and nonprescription), insect stings and bites, food, and any other substances (such as latex) surgeries and hospitalizations.

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