Patient records are organized documents created to obtain a patient's medical history and previous treatments. Medical records are personal documents stored by your doctor. Each medical record contains enough information to distinguish each patient. Contains the first and last name with gender and age. Each patient's medical records are different, some contain more information due to their medical history. If a patient has many problems and has been treated, his or her record will contain more information. Some documents also contain history of complaints and procedures, few documents contain photographs with a brief summary of what is present. Medical records can be stored electronically, traditionally handwritten, and even recorded by voice. Medical records written on paper and stored in folders are divided into information sections. Contains medical terminology that anyone in the medical field can read. It should be written in black or blue ink. Each provider should always document the evaluation and findings of each visit during the visit. Predating or backdating an entry is prohibited. If there is an error written in the wrong medical record, this should be dated and signed by the person reviewing the record; this shows that it has been corrected. The purpose of a medical record is for the healthcare provider to provide endless care to the individual patient. It serves as a source for planning patient care and services provided to that patient. The medical record begins with the patient's birth. It contains diseases, infirmities and everything the patient tells his doctor about his past and present state. It also contains laboratory test results and medications that have been prescribed. It also contains allergies, ordered referrals to other healthcare providers, and plans for further treatment. The patient's medical history includes family history and death status of family members, if known. It tells about the patient's relationships, his career and his educational background, this helps the doctor to know and explain the behavior of a patient in relation to the illness or loss. It contains several habits such as smoking, alcohol use, diet and exercise. Included is vaccination history and blood test demonstrating immunity. If a patient is hospitalized there are daily updates that are entered into the medical record; documents clinical changes and new information.
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