Health Care Records and Technology
Part 1
It is imperative that a medical record have specific personal identification information, such as, a state, or government issued identification in order to ensure the accuracy of the medical record to the correct patient. We often will also find facility specific information as well, but all of the information found in the medical record must have detailed personal information. A medical record should also have the medical history of a patient that shows all diagnoses, medical care, treatments, and allergies. This information lets medical personnel know about your current symptoms like whether an illness is chronic or acute, or whether it is something new. The patient’s allergy information is also within the medical record and is important to keep up to date because it could actually save the patient’s life.
The family medical history is also in a patient’s medical record and is an important part as well because some health risks are genetic. Knowing that a mother, father, or grandmother has had a heart condition or cancer is very beneficial to a patient’s care. There are many diseases out there that are genetic even though they may not show in every generation those genetic markers could shed light on a current set of symptoms. The more information the physician has on family history the better. Another piece to a medical record is medication history whether it is prescribed, over the counter, or even illegal drugs is important for the medical professional to know. It could affect treatment of an patient in negative ways that is why it is very important that you let the medical professional know exactly what you are taking or been taking since your last visit.
The treatment history is a part of the medical record also it lets the health care professional know what treatments you have had in the past and whether they worked or not. This...