What information can be found in a medical record?
It includes informationally typically found in paper charts as well as vital signs, diagnoses, medical history, immunization dates, progress notes, lab data, imaging reports and allergies. Other information such as demographics and insurance information may also be contained within these records.
What are 5 different things that you may find in a patient's medical records?
The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
What are the four common data that may be captured in a health record?
Data types commonly extracted from EHRs and imported into registries are patient identifiers, demographics, diagnoses, medications, procedures, laboratory results, vital signs, and utilization events.
What is considered sensitive information in a medical record?
2 Despite a range of opinions about what qualifies, in general sensitive health information is considered to be information that carries with it unusually high risks in the event of disclosure.
What are the 12 main components of the medical record?
12-Point Medical Record Checklist : What Is Included in a Medical...Patient Demographics: Face sheet, Registration form. ... Financial Information: ... Consent and Authorization Forms: ... Release of information: ... Treatment History: ... Progress Notes: ... Physician's Orders and Prescriptions: ... Radiology Reports:More items...•
What are the types of records in nursing?
Nursing: RecordsPatients Clinical Records. It is the record of events in the patient illness, progress in his or her recovery and the type of care given by the hospi-tal personnel.Individual staff records. ... Ward Records. ... Administrative records.
What are 5 reliable sources of health information?
health brochures in your local hospital, doctor's office or community health centre. telephone helplines such as NURSE-ON-CALL or Directline. your doctor or pharmacist. reliable health information websites, such as government sites, condition-specific sites, support organisation sites, and medical journals.
What are four sources that you can use to get information about your patient?
Surveys.Medical Records.Claims Data.Vital Records.Surveillance.Peer-Reviewed Literature.Quiz.
What are examples of clinical data?
Clinical data falls into six major types:Electronic health records.Administrative data.Claims data.Patient / Disease registries.Health surveys.Clinical trials data.
What are five types of sensitive data?
What Is Considered Sensitive Information?PII — Personally Identifiable Information.PI — Personal Information.SPI — Sensitive Personal Information.NPI — Nonpublic Personal Information.MNPI — Material Nonpublic Information.Private Information.PHI / ePHI — (electronically) Protected Health Information.More items...•
What are three types of sensitive information?
The three main types of sensitive information that exist are: personal information, business information and classified information.
What all data can be considered sensitive?
What personal data is considered sensitive?personal data revealing racial or ethnic origin, political opinions, religious or philosophical beliefs;trade-union membership;genetic data, biometric data processed solely to identify a human being;health-related data;More items...