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

Determine the improper occlusal scheme, Improper Occlusal Scheme This i...

Improper Occlusal Scheme This is an important cause of failure as the implant are more sensitive to occlusal trauma and leads to prosthetic failure and bone loss. The susceptib

Explain behavioural counseling, Behavioural Counseling This evolved fro...

Behavioural Counseling This evolved froni tlie early theories  of  behaviourism.  The focus is on examining current behaviours and learning new ones.  It is believed that feeli

Conduction system - heart, In this unit, you have learnt that heart is a mu...

In this unit, you have learnt that heart is a muscular organ situated in thorax covering with pericardium and consist of four chambers i.e. right atrium, left atrium, right ventric

Regents for estimation of reducing sugar by fehling soxhlet, Define Regents...

Define Regents for Estimation of Reducing Sugar by Fehling Soxhlet Method? Fehling A solution - copper sulphate solution Fehling B solution - alkaline tartarate so

Auxins, Auxins Auxins are plant growth substances. The term Auxin us...

Auxins Auxins are plant growth substances. The term Auxin usually refers to a chemical compound called Indole Acetic Acid (IAA), which is the major natural auxin. In plan

Special situations of pulmonary embolism, Q. Special situations of Pulmonar...

Q. Special situations of Pulmonary Embolism? The CXR is often abnormal in pulmonary embolism. Atelectasis and other focal pulmonary parenchymal abnormalities are the most commo

Erythema - common disorders of skin, Erythema: Erythema is one of  the...

Erythema: Erythema is one of  the,commonest primary lesions of  the skin. It  is produced by  the dilation of the cutaneous blood vessels.  If the dilation  is accompanied  by

Tracheostomy care, Tracheostomy Care A tracheostomy is an external ope...

Tracheostomy Care A tracheostomy is an external opening made into the trachea in order to provide an artificial airway (an opening is made in the 2nd and 3rd or 4th trach

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