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Prenatal records typically include a comprehensive baseline prenatal health history form, risk assessment tools, and additional forms or flow sheets for on-going documentation of care during prenatal visits and childbirth [4].
Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.
Insight into the status and complications of a patient's current and previous pregnancies can aid in the early diagnosis and management of any issues that may arise.
What are medical charts? The complete record that contains all clinical data and health record of a patient, medical chart includes demographics, diagnoses, vital signs, treatment plans, medications, problems, progress notes, allergies, immunization details, lab results, and radiology images.
Basics of history taking Chief concern (CC) History of present illness (HPI) Past medical history (PMH) including preexisting illnesses, medication history, and allergies. Family history (FH) Social history (SH) Review of systems (ROS)

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What Documents Need Redaction Driver's license numbers. Date of birth. Social security numbers. Addresses & phone numbers. Account numbers. Financial information. Medical & psychiatric information. All other personally identifiable information (PII)
The components of a prenatal record include all the initial demographics, family, and personal medical and genetic history, complete physical examination and laboratory testing, and provides room for additional records and serial examinations to be recorded in a fashion to allow trending.
12-Point Medical Record Checklist : What Is Included in a Medical... Patient Demographics: Face sheet, Registration form. ... Financial Information: ... Consent and Authorization Forms: ... Release of information: ... Treatment History: ... Progress Notes: ... Physician's Orders and Prescriptions: ... Radiology Reports:
If documentation doesn't give a clear presentation of a patient's history, it is termed improper documentation. Thus, this study aims to determine the level of patient documentation practice and ascertained the technical knowledge possessed by health record staff practicing documentation.
Record of the patient's care that includes vital signs, particularly temperature (T), Pulse (P), Respiration (R), and blood pressure (BP). The procedures, and patient's responses to such care.

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