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Medical Record

The document discusses the importance of proficiency in navigating a patient's medical record. It describes the key components of a medical record, including the medical history, laboratory and diagnostic test results, problem list, clinical notes, and treatment notes. It also notes some common issues that can arise when navigating a medical record, such as missing details, information in the wrong location, conflicting information, and difficulty locating all information. Developing an accurate problem list requires synthesizing information from a patient's disease states and drug-related problems documented in the medical record.

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Muhammad Deri Ramadhan
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99 views20 pages

Medical Record

The document discusses the importance of proficiency in navigating a patient's medical record. It describes the key components of a medical record, including the medical history, laboratory and diagnostic test results, problem list, clinical notes, and treatment notes. It also notes some common issues that can arise when navigating a medical record, such as missing details, information in the wrong location, conflicting information, and difficulty locating all information. Developing an accurate problem list requires synthesizing information from a patient's disease states and drug-related problems documented in the medical record.

Uploaded by

Muhammad Deri Ramadhan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MEDICAL RECORD

NS. M. DERI R., M.KEP


IMPORTANCE OF PROFICIENCY
IN NAVIGATING
THE PATIENT’S MEDICAL RECORD
Because most encounters with patients occur over more
than one point in time, the use of a medical record
facilitates the documentation of all data collected over
time.
In both the hospital and clinic settings, the medical record
takes the form of a patient chart composed of printed
materials in a folder or binder (paper-based chart) or
within a computer system (electronic medical record), or a
combination of the two.
COMPONENTS OF A PATIENT’S MEDICAL RECORD

The medical record can be dissected into Medical History (Patient demographics,
five primary components, including the Chief complaint (CC), History of present
medical history (often known as the illness (HPI), Past medical history (PMH),
history and physical, or H&P), laboratory Family history (FH), Social history (SH),
and diagnostic test results, the problem Allergies, Medication history, Review of
list, clinical notes, and treatment notes systems (ROS), Physical examination (PE),
LABORATORY TEST RESULTS
Most patients will have a basic metabolic panel and complete
blood count (CBC) in addition to other parameters specific to
their diagnosis and medical conditions, including, but not
limited to, cardiac enzymes, serum drug concentrations, liver
function tests, and cultures of blood or other body fluids.
DIAGNOSTIC TEST RESULTS
Such results may include electrocardiograms,
echocardiograms, ultrasounds, computed tomography (CT)
scans, magnetic resonance imaging (MRI) scans, x-rays, and so
on.
PROBLEM LIST

The problem list notes, in decreasing order of priority, the


issues that require management in the individual patient.
CLINICAL NOTES
Nurses maintain their own clinical notes within the computer
system or on a bedside chart. Often these include
documentation of vital signs, pain assessments, patient
activities (e.g., out of bed to chair, bathroom visits), and
quantity of fluid a patient ingests and excretes (e.g., ins and
outs).
TREATMENT NOTES
Treatment notes include medication orders, medication
administration records (MARs), documentation of surgical
procedures, and documentation of services such as radiation
therapy, physical therapy, occupational therapy, respiratory
therapy, and nutrition.
ELECTRONIC AND PAPER-BASED DATA
COLLECTION SYSTEMS
As technology continues to advance in the healthcare arena,
the capabilities of electronic medical record formats continue to
expand, including providing improved accessibility of patient
data via handheld mobile devices
SEVERAL ISSUES CAN ARISE
WHEN NAVIGATING THE
CHOPPY WATERS OF THE
MEDICAL RECORD.
MISSING
DETAILS
INFORMATION IN THE
WRONG LOCATION
ON THE CHART
INFORMATION IN THE
WRONG LOCATION
ON THE CHART
CONFLICTING
INFORMATION
LOCATING ALL OF THE
INFORMATION
SYNTHESIZING PATIENT INFORMATION:
DEVELOPING A PROBLEM LIST

Disease States Drug-Related


Problems
THANK YOU

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