The college of physician and surgeons cited that, the
medical record is a powerful tool that allows the treating physician to track
the patient medical history and identify problems or pattern that may help
determine the course of health care College of Physician and Surgeon (2012) the
primary purpose of the health record keeping it to enable physicians to provide
quality health care to their patient. It is living document that tells the
story of the patient and facilitate each encounter they have with health
professionals involved in their care. In addition to telling the patient story,
complete and accurate health record will meet all legal, regulatory and
auditing requirement. Most immortally, however, they will contribute to
comprehensive and high quality care for patient by optimizing the use of
resources improving efficiency and co-ordination in team base and inter
professional setting and facilities research.
medical record is a powerful tool that allows the treating physician to track
the patient medical history and identify problems or pattern that may help
determine the course of health care College of Physician and Surgeon (2012) the
primary purpose of the health record keeping it to enable physicians to provide
quality health care to their patient. It is living document that tells the
story of the patient and facilitate each encounter they have with health
professionals involved in their care. In addition to telling the patient story,
complete and accurate health record will meet all legal, regulatory and
auditing requirement. Most immortally, however, they will contribute to
comprehensive and high quality care for patient by optimizing the use of
resources improving efficiency and co-ordination in team base and inter
professional setting and facilities research.
The purpose of health records keeping are to store a
chronological account of the patient illness, it contest and who did what to
what effect, to aid communication between team members, to allow conformity of
approaches in a continuing illness, to record any special factors that appears
to affect the patient or the patients response to treatment, to record and
factor that might render the patient more vulnerable to an adverse reaction to management
or treatment, to record advice given by general practitioners, other clinicians
and other agencies, to inform research to allow constitution to national data
sets, morbidity register etc, use to increase the assessment of professional
competences.
chronological account of the patient illness, it contest and who did what to
what effect, to aid communication between team members, to allow conformity of
approaches in a continuing illness, to record any special factors that appears
to affect the patient or the patients response to treatment, to record and
factor that might render the patient more vulnerable to an adverse reaction to management
or treatment, to record advice given by general practitioners, other clinicians
and other agencies, to inform research to allow constitution to national data
sets, morbidity register etc, use to increase the assessment of professional
competences.
