the term for a collection of data recorded when a patient seeks medical treatment answer

What is a medical record used for?

medical record a collection of data recorded when a patient seeks medical treatment concise, complete, clear, correct, chronologically ordered the 5 Cs used to describe the necessary attributes of entries to patients' medical records invasion of privacy

What is medical history record PDF template?

medical record. A collection of data recorded when a patient seeks medical treatment. doctrine of professional discretion. A principle under which a physician can exercise judgment as to whether to show patients whoa are being treated for mental or emotional conditions their records. Disclosure depends on whether, the physician's judgment, such patients would be harmed by …

What should be carefully labeled and preserved in medical records?

A collection of data recorded when a patient seeks medical treatment. ... Record Purposes. 1. Required by licensing authorities and provide a format for tracking, documenting, and maintaining a patient's communication data, both inside and outside a health care facility. ... (subpoena commands a witness to appear in court and to bring certain ...

Who owns the medical records of a patient?

a collection of data recorded when a patient seeks medical treatment. Addendum. ... and maintaining a patient's communication data, both inside and outside a health care facility ... Are you entitled to a copy of your own medical records on request? Explain your answer. Yes. You need to just sign a release form.

What is another name for patient medical records?

What is another word for medical record?medical historyanamnesisreportdocumentrecordfiledocumentationregisterannalsdata41 more rows

What is the recording of information in a patient's medical record?

Medical charts contain documentation regarding a patient's active and past medical history, including immunizations, medical conditions, acute and chronic diseases, testing results, treatments, and more.

What are patient records called?

The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.

What is the term given to any information about a patient?

INDIVIDUAL IDENTIFIABLE HEALTH INFORMATION (IIHI)- Any part of an individual's health information, including demographic information, collected from an individual that is received by a covered entity. ( health care provider) INFORMED CONSENT FORM.

What is medical records management?

Medical records management is a system of protocols and procedures responsible for governing, maintaining, and securing patient records throughout the data lifecycle.

What is medical records in hospital?

Medical Record contains the patient's identification information, the patient's health history and medical examination findings. Medical Record also contains a summary of the patient's current and previous medications a well as any medical allergies.

What is medical term EMR?

An electronic (digital) collection of medical information about a person that is stored on a computer. An electronic medical record includes information about a patient's health history, such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans.

What is a complete medical record?

A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.

What are the types of medical records?

01 Oct 6 different types of medical documentsPIL. A PIL is a patient information leaflet you can find in any medicine bought at a pharmacy. ... Medical history record. ... Discharge Summary. ... Medical test. ... Mental Status Examination. ... Operative Report.Oct 1, 2015

What kind of information is included in a patient's medical history?

A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.

What is an example of PHI?

Examples of PHI include: Name. Address (including subdivisions smaller than state such as street address, city, county, or zip code) Any dates (except years) that are directly related to an individual, including birthday, date of admission or discharge, date of death, or the exact age of individuals older than 89.Nov 24, 2021

Where is a detailed assessment of a patient's medical history?

The Notes tab in the EHR contains narrative information about a patient's current and past medical history. It is where all members of the health care team communicate about the patient during a hospital visit or while receiving outpatient care.

What are the findings of a vital signs assessment?

Assessment findings that include current vital signs, lab values, changes in condition such as decreased urine output, cardiac rhythm, pain level, and mental status, as well as pertinent medical history with recommendations for care, are communicated to the provider by the nurse.

What is the meaning of assessment in nursing?

Assessment (gather subjective and objective data, family history, surgical history, medical history, medication history, psychosocial history) Analysis or diagnosis (formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient)

What is psychosocial assessment?

Psychosocial Assessment. The primary consideration is the health and emotional needs of the patient. Assessment of cognitive function, checking for hallucinations and delusions, evaluating concentration levels, and inquiring into interests and level of activity constitute a mental or emotional health assessment.

What is nursing assessment?

The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process. Part of the assessment includes data collection by ...

When should a nurse complete admission history?

The nurse should strive to complete: Admission history and physical assessment as soon as the patient arrives at the unit or status is changed to an inpatient. Data collected should be entered on the Nursing Admission Assessment Sheet and may vary slightly depending on the facility.

What equipment do nurses need for physical exam?

The nurse should be familiar with the otoscope, penlight, stethoscope (bell and diaphragm), thermometer, bladder scanner, speculum, eye charts, cardiac and blood pressure monitors, fetal doppler and extremity doppler, and sphygmomanometer. Stretcher or bed for proper positioning during a physical exam.

What is notifiable disease surveillance?

Notifiable disease surveillance usually focuses on morbidity from the diseases on the list and does not cover mortality from those diseases. True. False. The list of diseases that a physician must report to the local health department is typically compiled by the…. Local health department.

What is vital statistics?

Vital statistics provide an archive of certain health data. These data do not become surveillance data until they are analyzed, interpreted, and disseminated with the intent of influencing public health decision-making or action. True. False.

What is public health surveillance?

A method to monitor occurrences of public health problems. A program to control disease outbreaks. A system for collecting health-related information. A system for monitoring persons who have been exposed to a communicable disease. Public health surveillance is only conducted by public health agencies.

What is a surveillance based on?

Syndromic surveillance based on symptoms, signs, or other characteristics of a disease, rather than specific clinical or laboratory diagnostic criteria. Both. Neither.

Why use a medical history record PDF?

Medical History Record PDF template is mostly used in order to provide significant information about the health history, care requirements, and risk factors of the patient to doctors. It is for collecting data from the patients.

What is a medical history document?

A comprehensive document providing the patients’ past medical history, personal and contact details, health information, habits, living standards and family medical history with their consent to the terms and conditions.

What is an occupational first aid assessment?

An Occupational First Aid Patient Assessment is a document that puts into record the injuries or signs or symptoms of diseases provided by the patient or his or her companion. This is recorded by an attendant and the records of such must be kept for historical purposes.This Occupational First Aid Patient Assessment PDF template is your easy to use document for your company. It contains the necessary questions required for a first aid assessment in order to help medical practitioners immediately see the information of their patients or for them to immediately get a lead of the patient's illness or injury.

What is a first aid incident report?

The First-Aid Incident Report template contains injured person's personal details and contact details, the details and visible symptoms of injury, the Glasgow Coma Scale which is a neurological scale that expects to give a dependable and target method for chronicle the condition of an individual's awareness and brief information of treatment. Also, it contains the profile of the first-aider and signature of the person who prepares the report. Plus, JotForm is HIPAA-compliant and that is gigantic in addition to for anybody in the medicinal services industry.

What is a BMI chart?

BMI Chart document useful for both individuals and dietitians to track and document their records. The report comes with a BMI Chart and provides body metrics of submitters with their BMI Score and the body type they fit in.

What is HIPAA law?

The Health Insurance Portability and Accountability Act of 1996 (or HIPAA) is a United States legislation that provides data privacy and security provisions for safeguarding medical information .

What is a dental health record template?

The Dental Health Record Template is easy for patients to fill out and designed to get the doctor the most important information. Patients can fill out their information on a computer or tablet using our Dental Health Record Template.