A Complete Overview of Medical Records
A medical record is the detailed written record that your doctor makes every time you visit to discuss a health issue. Your doctor’s assistant maintains a record file in which they add all the updated notes about your health issues. Many health care centres keep the patient record information in an electronic format so that it is easily accessible whenever required. These records are known as electronic health records or EHRs.
What is medical record all about?
Medical records are essential information maintained and stored by every health centre. The doctor can check the medical record to learn the patient’s history. With electronic records, medical health care centres can easily keep the data safe. For example, if your dermatologist or physician wants to prescribe some medication, they can check the record first. Doctors check the records to see if a new prescription could possibly react with other medications that you are already taking. These records help providers to give patients the best care.
What elements are included in the medical record?
Your Medical record is a very important document recording your health history throughout the decades. These records reflect your overall health issues and recoveries. The main elements that are included in the medical record are:
1) Identity of the patient: Every medical record must begin with identifying information about the patient, such as name, date of birth, social security or government-issued ID number.
2) Past health history: Every doctor will check the medical history before proceeding with the health check-up. Doctors review the history which includes past or present diagnosis, medical care, treatments, and allergies. Before prescribing any new medication, it is necessary to check the health history first.
3) Past family history: Family history plays a vital role in health, as some health issues are inherited and this information could help a doctor make a diagnosis. Therefore, the patient’s family history is an important part of the medical record.
How can you manage/organize medical records easily?
Management of medical records is essential. You can easily create your own medical file and update it regularly. Whenever you visit the doctor, make sure you record the visit and prescription in your own notes as well. This way, you can always check the particular file yourself whenever necessary.
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