Question: What Is The Purpose Of The Medical Record?

What is the primary purpose of the electronic health record quizlet?

No matter what term is used, however, the primary function of the health record is: To document and support patient care services.

What does data represent.

Data represent the basic facts about people, processes, measurements, conditions, and so on..

What are the three main types of health records?

Understanding the different types of health information…Electronic health record. Electronic health records, sometimes known as electronic medical records, are electronic systems that store your health records in place of the paper copy, according to Health IT. … E-prescribing. … Personal health record. … Electronic dental records. … Secure messaging.

Why do doctors ask for medical history?

A family medical history can identify people with a higher-than-usual chance of having common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and diabetes. These complex disorders are influenced by a combination of genetic factors, environmental conditions, and lifestyle choices.

What are the four purposes of medical records?

It tells the patient’s “story”: the presenting problem and the treatment received; Helps to plan and evaluate a patient’s treatment; Creates a permanent record for the patient’s future care; Builds a database to evaluate the effectiveness of treatment that may be useful for research and education.

Why is medical records important?

A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science.

What are the two types of medical records?

Terms in this set (20)EHR. Electronic health record that keeps basic profile information on a patient.Patient Data. Info that is provided by patient then updated as necessary. … Medical History (Hx) … Physical Examination (PE) … Consent Form. … Informed Consent Form. … Physician’s Orders. … Nurse’s Notes.More items…

What information is contained in the medical record quizlet?

Information contained in the medical records is? Health History, Results of the Physical Examination, Lab Reports, Progress Notes.

What do patients have the right to do to their medical records?

Everyone has the right to access personal data held about themselves in either computerized or manual form, whenever the record was made. This includes NHS medical records and private records made by doctors and other health professionals. You. Another person with your written permission.

What is the purpose of a medical record quizlet?

They provide a written account of a patient’s health care. Medical records can be used for legal purposes to protect patients and medical professionals. Who owns the information within a patient’s medical record?

What shows up in medical records?

Your records also have the results of medical tests, treatments, medicines, and any notes doctors make about you and your health. Medical records aren’t only about your physical health. They also include mental health care.

What are flowsheets in medical records?

A flow sheet is simply a one- or two-page form that gathers all the important data regarding a patient’s condition, in this case diabetes. The flow sheet is housed in the patient’s chart and serves as a reminder of care and a record of whether care expectations have been met.

What is the difference between medical record and health record?

It’s easy to remember the distinction between EMRs and EHRs, if you think about the term “medical” versus the term “health.” An EMR is a narrower view of a patient’s medical history, while an EHR is a more comprehensive report of the patient’s overall health.