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

Explain about the hypokalemia, Explain about the Hypokalemia? Normal s...

Explain about the Hypokalemia? Normal serum K ranges from 3.5-5 mM/L. Hypokalemia or low plasma K levels can occur with a net shift of K from the plasma to the cells. This shi

Plasma proteins - circulation, Plasma Proteins - Circulation The total...

Plasma Proteins - Circulation The total protein concentration of the plasma is around 7% only. The plasma proteins are of three types - serum albumin (4%), serum globulin (2.7

Define mechanisms for antinutritional effect on human, Define mechanisms fo...

Define mechanisms for antinutritional effect on Human? There are several possibilities: reduced availability of amino acids to cancer cells by reversing the carcinogen-induced

Describe about coronary reactive hyperemia, Q. Describe about coronary reac...

Q. Describe about coronary reactive hyperemia? Myocardium depends almost completely on aerobic metabolism. Occlusion of a coronary artery even briefly produces an increase in c

Name the hormones produced by the testes, Name the hormones produced by ...

Name the hormones produced by (a) the testes, (b) the ovaries.   (a) The testes produce testosterone. (b) The ovaries produce oestrogen and progesterone.

Are the limbs modified into wings of bats, Are the limbs modified into wing...

Are the limbs modified into wings of bats and the wings of birds examples of evolutionary analogy or homology? What about whale fins compared to fish fins? Bat and bird wings h

Precaution - separation of amino acid by paper chromatogrphy, Define Precau...

Define Precaution for Separation of Amino Acids by Paper Chromatography? 1. Hold the paper with the extra strip kept at one side. Handling of whatman paper with hand should be

What are the major features of the meristematic cells, What are the major f...

What are the major features of the meristematic cells? And why do these cells need to have a high mitotic rate? The Meristematic cells have very thin cell walls, a well-central

What is hypertrichosis of the ear, In humans, attached earlobes are a domin...

In humans, attached earlobes are a dominant feature over free earlobes while hypertrichosis of the ear is a holandric (Y-linked) feature. A person with attached earlobes and extens

Myocardial hypertrophy and remodeling, The long term adaptive mechanisms in...

The long term adaptive mechanisms involve myocardial hypertrophy and remodeling which occurs slowly over weeks to months. The capacity of these adaptive mechanisms meant to sust

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