·
Patient’s 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
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.
Patient’s 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
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.
·
Hospital Admission Records: 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. 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.
Hospital Admission Records: 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. 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.
·
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.
·
Hospital 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. 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 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. 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.
·
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.
