Medical Records Flashcards, test questions and answers
Discover flashcards, test exam answers, and assignments to help you learn more about Medical Records and other subjects. Don’t miss the chance to use them for more effective college education. Use our database of questions and answers on Medical Records and get quick solutions for your test.
What is Medical Records?
Medical records are essential to the effective delivery of patient care in today’s healthcare system. By providing a comprehensive and organized record of a patient’s health history, medical records allow for continuity of care between providers over time, which is critical for ensuring the best possible outcome for patients. In addition, medical records have a number of other important functions such as providing evidence in support of clinical decision making, facilitating communication between providers and helping to ensure quality care.Medical records can include a variety of information including the patient’s demographic and contact information, past medical history and current medications taken. They also provide insight into the severity or chronicity of diseases or conditions which may require additional monitoring or treatment. Furthermore, they provide documentation on treatments provided, laboratory results, imaging reports and notes from physicians about their assessment on visits. All these components combined make up a comprehensive record that allows healthcare professionals to quickly reference past data and make informed decisions about future care plans for their patients. In order to ensure accurate documentation within medical records it is important that all stakeholders involved understand best practices when recording information into an electronic health record (EHR) system or paper-based files. These practices should include regularly updating information throughout each visit with the patient as well as accurately entering notes about diagnosis or any other pertinent documentation necessary for continuity of care purposes. Additionally it is important that all documents stored within a medical record are properly dated so that healthcare professionals can easily identify what happened when in relation to specific events pertaining to individual patients.Overall medical records play an essential role in providing quality patient care by allowing clinicians access to detailed histories regarding their patients’ health status and individualized treatments plans while also ensuring legal protection against malpractice claims by documenting all aspects related to diagnosis and treatment decisions made by healthcare professionals over time.