Medical records, Biology

Assignment Help:

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

Related Discussions:- Medical records

Why do cells of the nephron tubules, Q. Why do cells of the nephron tubules...

Q. Why do cells of the nephron tubules present a great amount of mitochondria? The cells of the tubule wall have high number of mitochondria because many substances are secrete

Wind as a medium for dispersal, Wind as a medium for Dispersal Many mic...

Wind as a medium for Dispersal Many microorganisms, fungal spores and bacteria are freely transported over long distances even by moderate winds. In wind pollinated plants, the

J-shaped growth curve, J-shape d - It shows 2 phases - (i) Lay ph...

J-shape d - It shows 2 phases - (i) Lay phase (ii) Exponential phase

Explain about the nutrition security, Explain about the Nutrition Security?...

Explain about the Nutrition Security? Food security is a part of the broader concept of nutrition security. A household can be said to be nutritionally secure if it is able to

What is hypertension, Q. What is hypertension? The Hypertension is a di...

Q. What is hypertension? The Hypertension is a disease in which the arterial blood pressure, during systole or during diastole, is abnormally high. The Hypertension, or high

Define recommended dietary allowances for vitamin d, Define Recommended Die...

Define Recommended Dietary Allowances for Vitamin D? The recommendations of vitamin D are expressed as IU. 1 IU is defined as the activity contained in 0.025 mcg of cholecalci

Explain what is class osteichthyes , Explain what is Class Osteichthyes ? ...

Explain what is Class Osteichthyes ? Class Osteichthyes takes its name from the Greek root "osteo," referring to bone, and "ichthys," referring to fish. The bony fish have a sk

Define eye balling, Q. Define Eye Balling? Ans. Two-dimensional ec...

Q. Define Eye Balling? Ans. Two-dimensional echocardiography provides a good visual perception of cardiac functions. With experience, the echocardiologist learns to percei

Regulation of alkalinity and acidity of the plasma, Q. In which nephron por...

Q. In which nephron portion does the regulation of alkalinity and acidity of the plasma occur? The regulation of the acid-basic equilibrium of the body is done by the kidneys a

Supplementation for prevention of vitamin a deficiency, Define Supplementat...

Define Supplementation for prevention of vitamin A deficiency? Administration of large doses of vitamin A to children at risk has been the most popular approach to control nutr

Write Your Message!

Captcha
Free Assignment Quote

Assured A++ Grade

Get guaranteed satisfaction & time on delivery in every assignment order you paid with us! We ensure premium quality solution document along with free turntin report!

All rights reserved! Copyrights ©2019-2020 ExpertsMind IT Educational Pvt Ltd