Show The purpose of obtaining a health history is to gather subjective data from the patient and/or their care partners to collaboratively create a nursing care plan that will promote health and maximize functioning. A comprehensive health history is completed by a registered nurse and may not be delegated. It is typically done on admission to a health care agency or during the initial visit to a health care provider, and information is reviewed for accuracy and currency at subsequent admissions or visits. A comprehensive health history investigates several areas:
Each of these areas is further described in the following sections.
The “History and Physical” documentation in a patient’s electronic medical record is completed by a health care provider on admission to a health care agency. It is very similar to the health history obtained by a nurse and is helpful to read when caring for a patient for an overview of their treatment plan.
No one can deny the importance of keeping a medical record of a patient in an organised fashion. Whether the patient is in a hospital for long term care or is a regular patient at a local clinic, it is crucial for the caregivers to have the requisite information. Documentation of medical records makes it easy for medical professionals to access relevant information of patients. The two modes in which this documentation can be maintained are offline (that is the traditional, physical mode) or online. Online documentation of medical records is being preferred these days due to the convenience that comes with it. When it comes to health insurance and medical information, patient privacy is of enormous importance and cannot be overlooked. Electronic Medical Records or EMRs help both small clinics and hospitals to be within the legal compliance requirements. What is a Medical Record?Essentially, a medical record contains information related to the health of the patient. It also contains relevant medical information. Now, the extent to which the information will be detailed or broad will depend on the clinic collecting the information as well as the patient’s consent. Components of a Medical RecordAs stated earlier, what exactly is contained in a medical record is often subjective and depends on the need and consent of the patient. However, there are certain basic components of a medical record that can be ascertained to be essential ones. We discuss some of them below. 1) Patient Identity – Patient identification is crucial in order to match the database to a subject. It is around this subject that all the information will revolve. Most likely, this subject is a combination of your name and one more differentiating piece of information. This second piece of information can be your date of birth, address or social security number. Needless to mention, all this data is more secure when online medical records are used. 2) Patient’s Medical History – It is interesting to note that there are legal medical record standards. Any electronic medical record has to meet these standards. One of the essential components of a medical record is that particular patient’s medical history.In order to treat you better, the medical professional has to be aware of your medical past, whether you have any immune system disease, hypertension, diabetes, etc, whether you are allergic to any food item or medicine. All this information in a medical record helps the doctor treat you better. 3) Family History – Of course, when we talk about family history, we do not mean the names and details of your ancestors. We refer to their medical history. There are certain diseases which are hereditary in nature. Some of the most common hereditary diseases are also the most dangerous. However, the good news is that if you are aware of any genetic predisposition to a particular disease, there are ways to mitigate the circumstances. It is here that family history as part of medical record makes a huge difference.  4) Treatment History – Did you know that many times, if you have been given a particular medication, you cannot be given the same medication before a certain time period is over? Further, if your treating physician is not informed about any recent or past surgeries that you had to get done, he may be making a mistake by prescribing you certain medication. A Medication checklist is also an important component of a Medical Record as it helps the physician or caregiver ensure that patients are taking the right medicines at the right doses and times and that there are no conflicts or adverse interactions between different medications. A patient’s treatment history might not seem very interesting to the patient himself. Often, patients want to hide the past treatment, especially when they wish to take a second opinion. Nevertheless, it is an integral component of their medical record. 5) Patient Directions – Yes, we went there. We get it. You do not want to think or talk about death. But in very rare circumstances, you might be in a medical state when you are unfit to take a decision. In that case, do you want someone else to decide for you? Even if you want others to decide, they may not want to take such a big decision. In these scenarios, a living will helps. Also, you may have a DNR (Do Not Resuscitate) directive for yourself. This is crucial information that must be on a medical record. In the digital age, while people are willing to give away lots of personal information to their smartphone and internet providers, there is a skepticism when it comes to sharing private medical information. This is rightly so. One of the ways to encourage more and more people to share requisite and correct information with their healthcare provider is to show them that their data is secure. Under HIPAA Privacy Rule also, a patient has the right to access and even amend their medical data. As more and more people are made aware of the safeguards implemented for online medical records, surely adaptability will improve. May 9, 2022 It is common practice for healthcare facilities in most of the developed countries to utilise electronic health records (EHRs). With these records, hospitals can speed up various processes and optimise their service that ultimately benefits the patients. But, what are the key components and benefits of the EHR software? Let us take a look. What do EHRs contain and why are they important?EHRs contain many generic and treatment-specific details about every patient that visits the medical facility. It contains information such as:
Manually keeping note of various statistics for every patient is a time consuming and near impossible task that massively reduces productivity in the healthcare industry. What’s more, medical staff are humans too; by keeping manual notes, errors may occur. In the unfortunate event that some information gets lost, it could lead to blunders! This is where the digital medical records component comes into the picture as it simplifies all these worries by keeping track of everything in a digitised format. Let us understand the key components of EHRs. Key components of a medical record:Given below are the major components of a medical record: Collection of important dataData collection and keeping it secure is one of the major functions of EHR software. These are the types of data that are collected by the software:
E-prescriptionsWith the pandemic raging from time to time, patients are more worried about their health now than ever before. They prefer scheduling appointments online with their doctors as they do not want to step out and risk their health unnecessarily. As a result, electronic prescriptions have become very popular. How does it work? The EHR software is fed with electronic prescriptions that make it easy for doctors to prescribe medicines to each individual patient through the software itself. What’s more, the patient can send this to their pharmacy and collect the medicines when they are available. Alternatively, many hospitals with pharmacies within also deliver the medicines at the patient’s doorstep. Hence, hospital management software is extremely useful to hospitals. Online appointment schedulingAccording to a study conducted by Kyruus, the majority of patients prefer to schedule appointments and talk to their doctor online ever since the Covid-19 pandemic. Through hospital management software and EHR, scheduling all the patients for appointments based on the availability of the doctors becomes a fairly easy task. The EHR also allows the patient to view the list of doctors and allows them to choose their preferred specialist. Then, they book an appointment based on that specialist’s schedule. Prior to the appointment, the patient receives reminder notifications via text or call. This reduces the chances of patients missing the appointment, thus, causing the medical facility to lose money. Lab interfacesLab results help doctors in making accurate decisions to provide the best possible healthcare to their patients. EHRs are highly useful in storing these lab results. Through the EHR software, doctors can directly request for reports in various formats. Once they view it, they can pass it on to the patients along with their suggestions. Clinical supportBy sending alerts and reminders about tests and examinations to patients under constant supervision, doctors can check-in with them periodically. The software can be programmed for each patient individually. Billing functionsBy integrating features of the accounting department into the software, the billing functions can be taken care of too. Through APIs and payment gateways, the system will be able to process payments through various methods such as cash, card, online transactions, etc. Generate data reportsEHR software has more uses than just scheduling appointments, keeping track of inventory and collecting data. One of the key functions of the software is analytics. Through the data reports generated by the software, healthcare facilities can easily analyse both their clinical as well as financial performances. Every healthcare facility needs to generate these two types of reports:
Also Read: Best practices to improve patient flow in the clinic ConclusionWhether you are seeking to create your own hospital management software or are upgrading to a full-fledged system, these are the key components you need to look for. Our hospital software consists of not only EHR functions, but also various other vital components your facility requires. Contact us today to schedule an appointment! |
What are the 4 components of a patients medical history?
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