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Hospital admission records: This is a record of a patient’s admission in a
hospital. This records
document the reasons why a patient is being admitted for inpatient care to a
hospital or other facility, the patient’s baseline status, and the initial
instructions for that patient’s care. Health caregivers use this record to assess
a patient’s baseline status and may write additional on-service notes, operative
notes, postoperative notes, procedure notes, delivery notes, postpartum notes,
Hospital admission records: This is a record of a patient’s admission in a
hospital. This records
document the reasons why a patient is being admitted for inpatient care to a
hospital or other facility, the patient’s baseline status, and the initial
instructions for that patient’s care. Health caregivers use this record to assess
a patient’s baseline status and may write additional on-service notes, operative
notes, postoperative notes, procedure notes, delivery notes, postpartum notes,
progress
notes (SOAP notes), preoperative notes, and discharge notes. The components of hospital
admission records include the header,
chief complaint (CC), history of present illness (HPI), allergies, past medical
history (PMHx), past surgical history (PSurgHx, PSxHx), family history (FmHx),
social history (SocHx), medications, review of systems (ROS), physical examination,
assessment and plan
·
Consultation notes: Consultation notes is a medical records maintained to keep
records of consultations including consultations outside normal opening hours,
home or other visits and telephone or electronic communications which are of
clinical significant, consultation notes comprise date of consultation, patient reason for consultation,
relevant clinical findings, diagnosis, recommended management plan and, where
appropriate, expected process of review, any medicines prescribed for the
patient (including name, strength, directions for use/dose frequency, number of
repeats and date medicine started/ceased/changed), complementary medicines used
by the patient, any relevant preventive care undertaken, any referral to other
healthcare providers or health services, any special advice or other
instructions, who conducted the consultation (e.g. by initial in the notes, or
audit trail in an electronic record), any other relevance information on
patient’s consultations.
Consultation notes: Consultation notes is a medical records maintained to keep
records of consultations including consultations outside normal opening hours,
home or other visits and telephone or electronic communications which are of
clinical significant, consultation notes comprise date of consultation, patient reason for consultation,
relevant clinical findings, diagnosis, recommended management plan and, where
appropriate, expected process of review, any medicines prescribed for the
patient (including name, strength, directions for use/dose frequency, number of
repeats and date medicine started/ceased/changed), complementary medicines used
by the patient, any relevant preventive care undertaken, any referral to other
healthcare providers or health services, any special advice or other
instructions, who conducted the consultation (e.g. by initial in the notes, or
audit trail in an electronic record), any other relevance information on
patient’s consultations.
·
Patient’s treatment records: Patient’s treatment record is a records maintained
on the treatment received by a patient. The patient’s treatment record is
classified as inpatient or outpatient treatment records. Components of patient’s
treatment records include date of treatment, name of patients, age of patients,
gender, address of patients, ailment suffered by patients, treatment received.
Patient’s treatment records: Patient’s treatment record is a records maintained
on the treatment received by a patient. The patient’s treatment record is
classified as inpatient or outpatient treatment records. Components of patient’s
treatment records include date of treatment, name of patients, age of patients,
gender, address of patients, ailment suffered by patients, treatment received.
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Hospital discharge records: This is a
document which records patient’s discharge from a hospital. A hospital discharge record is a formal release of
a patient from a hospital. There are two types of hospital discharge records
namely: emergency department (ER) and inpatient (IP) discharge records.
Hospital discharge data is collected from hospitals, including inpatient and
outpatient data. Hospital discharge records contain information on the date of
admission, date of discharge, patient’s age, gender, address of residence, and primary
and secondary diagnosis codes. Data from hospital discharge records are used to
examine important topics of interest in public health and for a variety of
activities by governmental, scientific, academic, and commercial institutions.
Hospital discharge records: This is a
document which records patient’s discharge from a hospital. A hospital discharge record is a formal release of
a patient from a hospital. There are two types of hospital discharge records
namely: emergency department (ER) and inpatient (IP) discharge records.
Hospital discharge data is collected from hospitals, including inpatient and
outpatient data. Hospital discharge records contain information on the date of
admission, date of discharge, patient’s age, gender, address of residence, and primary
and secondary diagnosis codes. Data from hospital discharge records are used to
examine important topics of interest in public health and for a variety of
activities by governmental, scientific, academic, and commercial institutions.
·
Patient’s test results records: This is a document which records patient’s medical
test results are the
results. This record include blood tests (e.g., complete blood count) radiology
examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized
testing (e.g., pulmonary function testing) are included..
Patient’s test results records: This is a document which records patient’s medical
test results are the
results. This record include blood tests (e.g., complete blood count) radiology
examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized
testing (e.g., pulmonary function testing) are included..
