Biostatistics and community engagement|| medical Record in hospital or healthcare Medical record.pptx

Biostatistics and community engagement|| medical Record in hospital or healthcare

1. Civics and community engagement Sadiq Amin Lecturer Radiology INU Swat

2. Medical record The medical record is the information about the patient’s medical history. OR A record of a patient’s medical information is called medical record/health record/medical chart.

3. CONT… THE PATIENT MEDICAL INFORMATION INCLUDE; Patient’s medical history and complaints Care or treatments received Physician physical findings Diagnosis Results of diagnostic test and procedure Medication and therapeutic procedures (surgery)

4. Medical record department Patient’s medical record keeping is the responsibility of medical record department of the hospital. This department is staffed by technically skilled personnel. Every hospital is required by law to maintain proper medical records of their patients.

5. Contents of medical record Admission sheet; this sheet is generally used for placing of the patient identification. It contains, Record number Patient’s name Address Gender Age Marital status Contact number

6. CONT…. Name and address of referring physician Admission diagnosis Date and time of admission Destination within the hospital 2. Admission history sheet; On the admission history sheet generally recorded the, Informants name Name of individual taking the history Patient’s chief complaints Description of patient illness

7. CONT… Admitting diagnosis Past diseases and illness Operation or major surgery experienced by the patient History of immunization, transfusion, reactions and complications Current medication Diet, height, weight Occupational history In case of female patient the pregnancies, their outcomes and complication Family history

8. 3. Physical examination sheet; it consist of a routine systemic review of, Skin, head and neck, chest, gastrointestinal, genitalia, lymph nodes, muscles and skeletal system, allergy and etc. This information helps the physician to proceeds for a suggested treatments program on medical record to be followed during hospitalization of the patient.

9. CONT… 4. Diagnostic sheet; the sheets are entered into the patient’s medical profile after each lab test and other diagnosis. This includes reports obtained from radiology, hematology, pathology as well as microbiology. 5. Medical record sheet; Recording of all treatment procedures Medication Definitive final diagnosis

10. 6. Autopsy sheet; this sheet is included if the patient dies during hospitalization . This contains complete protocol of the findings resulted from the autopsy.

11. Uses of medical records Serve as a basis for planning of patient care For continuity of patient care Provide a means of communication among the physician and other health care professionals Documentary evidence of patient illness and treatment during each hospital stay For legal purposes Provide data for use in presenting research and educational studies.

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