Example of Health Records Maintained in the Hospital

1. Tuberculosis Health Records

In maintain tuberculosis health records, health
care professionals keep information that can help in the management of TB.
These include:

·
Start and end dates for
treatments

·
Treatment results, including any
complications or side effects

·
Dates and details of other major
illnesses, chronic health conditions like heart disease

·
Patient’s family medical history

·
Patient TB diagnosis

·
Date of diagnoses

·
Copies of diagnostic test results

·
Treatment information

2. HIV Health Records

Maintaining HIV health
records involve keeping information such as:

·
HIV risk assessment
documentation and any HIV-related information.

·
Results of laboratory
tests, including tests for HIV.

·
Durable medical
equipment/adaptive devices currently used or required by patient (e.g.,
wheelchair, feeding pump, mechanical breathing supports, eyeglasses, hearing
aids).

·
Copies of exam reports from
primary providers and specialists, including
results of diagnostic tests and evaluations

·
Updated plan of care and
treatment provided to patient

·
Summaries of health care
planning meetings.

·
Names and addresses of the
primary and specialist provider(s).

·
Original consent forms
authorizing medical treatment for the patient.

·
Family health history,
including chemical dependency, mental illness, and hereditary conditions or
diseases.

·
Alcohol, drugs, or
medications taken by patient

·
Immunizations received by patient
prior to placement in care (type and
dates).

·
Medications prescribed for
the patient

·
Allergies (environmental,
food, medicine).

·
Significant acute, chronic,
or recurring medical problems; illnesses; injuries; and surgical operations.

·
Date and place of
hospitalization, including psychiatric.

3. Rehabilitative Health Records

In the
maintenance of rehabilitative health records information to be kept include:

·
Update the health log of
medical conditions, including additional times in the hospital and any
additional surgeries.

·
Include all healthcare
providers that are involved in health care, including physicians, other medical
personnel and healthcare agencies.

·
List any recent
immunizations received by patient.

·
List any medical equipment used
by patient, including vendor contact information.

·
Other medical information
that is important for someone to know.

·
Update on emergency contact
information and hospital preference as changes occur.

·
Update the list of
medicines taken by patient, including the dose and how often you take the
medicine and what condition the medicine is for.

·
Write down any known
allergies or reactions to medicine.

4. Cancer Health Records

The maintenance of a cancer
health records should include the following information:

·
Start and end dates for all
treatments

·
Treatment results, including any
complications or side effects

·
Information about palliative
care, including medications or procedures used to treat pain, nausea, or other
side effects, as well as other types of care, such as occupational therapy or
nutritional support

·
A schedule for follow-up care

·
Complete contact information for
doctors and treatment centres involved in your diagnosis and treatment

·
Contact information for other
doctors, such as your family doctors (past and current)

·
Dates and details of other major
illnesses, chronic health conditions like diabetes or heart disease, and
hospitalizations

·
Patient’s family medical history

·
Details of past physical
examinations, including cancer screening tests and immunizations

·
Patient diagnosis, including the
specific cancer type and stage. The stage describes where the cancer is
located, if it has spread, and whether it is affecting other parts of the body.

·
Date of diagnoses

·
Copies of diagnostic test results
and pathology reports

·
Complete treatment information,
such as chemotherapy drug names and doses or the sites and doses of radiation
therapy

5. Mental Health Records

A mental health record is
the records of psychological services received by a patient. This record can be
maintained by keeping client information such as:

·
contact information (e.g.,
phone number, address, next of kin)

·
date of service and
duration of session

·
types of services (e.g.,
consultation, assessment, treatment, training)

·
client responses or
reactions to professional interventions

·
current risk factors in
relation to dangerousness to self or others;

·
other treatment modalities
employed, such as medication or biofeedback treatment

·
emergency interventions
(e.g., specially scheduled sessions, hospitalizations)