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

Class holothuroidea, Class Holothuroidea Body cucumber-such as; no ar...

Class Holothuroidea Body cucumber-such as; no arms; no spines; no pedicellariae; ossicles minute and embedded in muscular wall; anus present; tube feet along with suckers; am

Explain vegetable dehydration, Explain Vegetable dehydration It reduces...

Explain Vegetable dehydration It reduces the natural water content below the level critical for the growth of microorganisms (12-15%), without being detrimental to important nu

Steps to determine thermal resistance of microorganism, Define Steps To det...

Define Steps To determine thermal resistance of a microorganism? Most food components and microorganisms obey first order reaction kinetics, which means that the destruction ra

Which of mendel''s postulates demonstrated in crosses, Which of Mendel's po...

Which of Mendel's postulates can only be demonstrated in crosses involving at least two pairs of traits? a) Segregation b) dominance/recessiveness c) independent assortment d) unit

What is vascular, Vascular Preoperative administration of a cephalospor...

Vascular Preoperative administration of a cephalosporin decreases the incidence of postoperative surgical site infection after arterial reconstructive surgery on the abdominal

Symptoms of non-ketotic hyperosmolar diabetic coma, Q. Symptoms of Non-Keto...

Q. Symptoms of Non-Ketotic Hyperosmolar Diabetic Coma? Following are the signs and symptoms of NKHDC: 1) Polyuria 2) Polydipsia 3) Weight loss 4) Mental Confusion

How do taenias classify according to the division of sexes, How do taenias ...

How do taenias classify according to the division of sexes? Taenias are monoecious (hermaphrodite), the similar individual has female and male reproductive organs and undergoes

What are the possible phenotypes of the progeny, A (w+/ w+) red-eyed Drosop...

A (w+/ w+) red-eyed Drosophila female is crossed with a white-eyed male. Assuming the trait for eye colour is sex-linked, what are the possible phenotypes of the progeny?

Monosaccharide sugars, Monosaccharide Sugar - carbohydrate consisting o...

Monosaccharide Sugar - carbohydrate consisting of a single sugar unit Have an aldehyde or a ketone group and 2-5 alcohol groups depending of the # of carbons

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