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

Experiments of mendel - monohybrid crosses, EXPERIMENTS OF MENDEL MONO...

EXPERIMENTS OF MENDEL MONOHYBRID CROSSES When only a single pair of contrasting or differentiating traits is considered in a cross (or inheritance of only one pair of cont

What is the way of life of sponges, Q What is the way of life of sponges? ...

Q What is the way of life of sponges? Sponges live exclusively in an aquatic environment and they are attached by their base to a substrate fixation ground. Sponges are filteri

Ethylene production - responses to infection, Ethylene production - Res...

Ethylene production - Responses to Infection Ethylene is also induced in response to infection. It is also known to be produced under other stress conditions like wounding

Enumerate the term - pathognomic sign, Enumerate the term - pathognomic sig...

Enumerate the term - pathognomic sign A comprehensive assessment ideally uses all four approaches. Some forms of specialised assessment rely heavily on pathognomic signs, behav

Explain gluconeogenesis, Explain Gluconeogenesis Gluconeogenesis (i.e...

Explain Gluconeogenesis Gluconeogenesis (i.e synthesis of  new  glucose)  is  the  synthesis of carbohydrate from  non-carbohydrate, source. The major  substrates for glucone

Diagnosis and treatment of infective endocarditis, Diagnosis Health hi...

Diagnosis Health history - any recent surgery/dental procedures, history of heart disease, recent infectious diseases, etc. Clinical Manifestation Laboratory

Testes (testicles), TESTE S (TESTICLES) - 2 in number (Diarchic). P...

TESTE S (TESTICLES) - 2 in number (Diarchic). Pinkish in colour. Oval shaped. 4-5 cms long, 2.5 cm wide and 3 cm thick. Mesodermal. In embryonic stage attached to kid

Factors affecting the rapeutic relationship, FACTORS AFFECTING THE RAPEUTIC...

FACTORS AFFECTING THE RAPEUTIC RELATIONSHIP: A  rapport  is developed between the nurse and  the patient. Rapport  is defined as, a relationship of mutual sympathy and underst

Extravascular compression, Most of the coronary blood flow to the left vent...

Most of the coronary blood flow to the left ventricular myocardium occurs during diastole. Thus the contracting heart obstructs its own blood supply. The systolic compressive force

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