Medical records, Biology

Medical Records

This includes:

  1. health history of patient/client 
  2. a report of the findings on examination 
  3. signs and symptoms 
  4. observation records 
  5. progress notes 
  6. discharge summary 
  7. instruction to be followed at home 

The following items are included in patient's/client's record:

  1. identification data 
  2. complaint, reason for seeking medical aid 
  3. present illness 
  4. past history 
  5. family history - 
  6. physical examination 
  7. special examinations 
  8. provisional and final diagnosis 
  9. treatment medical/surgical 
  10. pathologist's report 
  11. Maintenance of Records 
  12. progress notes 
  13. condition on discharge 
  14. follow-up records 
  15. autopsy findings 
  16. day to day nurses notes
Posted Date: 10/27/2012 7:29:12 AM | Location : United States







Related Discussions:- Medical records, Assignment Help, Ask Question on Medical records, Get Answer, Expert's Help, Medical records Discussions

Write discussion on Medical records
Your posts are moderated
Related Questions
Q What is the kind of digestive system of echinoderms? Echinoderms present a complete digestive system with anus and mouth. Q. Do sea urchins have teeth? Sea urchins ha

REDISCOVERY OF MENDEL'S LAWS (THE BIRTH OF GENETICS) 1.         It was in 1900 that three botanist independently rediscovered the principles of heredity already worked out by M

What are the main constituents of the earth's atmosphere in our time? The present atmosphere of the earth is constituted mostly of molecular nitrogen (N2) and molecular oxygen

A cat has just arrived to the veterinary clinic with low blood pressure. The cat weighs 5 kg, and as the on call Vet you want to use a bag of saline to prepare a dopamine drip for

what is rennin? how does it work? and what is its optimum pH level and activity temperature?

What are the inheritance and dominance patterns of the Rh blood system? An inheritance pattern of the Rh blood system is autosomal dominant that is the heterozygous manifests a

Endothelium - Ovule In plants bearing unitegmic ovules, the nucellus degenerates during early stages of ovule development and the embryo sac comes in contact with the innermos

what is the role of liver for the metabolism of carbohydrates

Actions of Estrogens The most general effect of the estrogens is to promote tissue growth. It is more pronounced in the accessory sex tissues. Estrogens stimulate cell divi

Explain diet from Lifestyle Risk Factors ? The lifestyle factors are the way of living of an individual and comprise of the diet, smoking, alcohol, physical activity and stress