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Types of medical records-manual and electronic

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In an ambulatory care setting, there are two types of medical records: manual and electronic. The information inside a medical record is essential for an ambulatory care setting because it details a type of office visit, diagnosis, services and procedures rendered, and most importantly the continuity of patients' care. You, as a healthcare provider, must know the content of a medical record and how to interpret that information to better serve your patients. The following is a list of items that you might find in a medical record:

Biopsy reports

Clinical notes

Consultation report

Daily reports

Discharge summaries

Emergency report

Laboratory report

Operative report

Pathology report

Patient History

Physical examination report

Progress note report

Psychiatric observations

Radiology report

Referral letters

Scan reports

SOAP note report

Therapy report

Please compose a one to two-page paper comparing and contrasting electronic and manual records. Also explain the difference between an electronic health record and an electronic medical record and describe the content found in a physical examination report, progress note, discharge summary, patient history, and consultation report.For example, a laboratory report is the result of any type of blood work performed in a healthcare environment, such as hematocrits/hemoglobin results, Sickle Cell, complete blood counts, cholesterol and lipid panels, Glucose Tolerance Test or GTT, VDRLs, and ELISA. Urinalysis and results for pregnancy tests are also laboratory reports. You can locate sources over the Internet or in your textbook to complete this assignment.

Reference no: EM132875594

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