Did you know about medical record? for those of you who do not know what a medical record, here’s a little re-associated with the medical record. Medical record Is a form of records containing:
- Medical record number (standardized, such as 7 digits: 0007279, not written in 7279).
- Patient Personal Identity: Name, date of birth, address, religion, sex, status.
- Family / Responsible Person: Name, address, religion, sex, family relationships.
- Date and time of inspection: Date and time.
- Vital Signs: Blood pressure, temperature, pulse, breathing, consciousness.
- History (Information), which consists of:
- Private Special Conditions: Allergy and blood disorders.
- Imun status.
- Current complaints.
- Past history of disease.
- Family history of disease.
- Physical examination.
- Diagnosis: primary diagnosis.
- Diagnosis (Differential Diagnosis).
- Additional diagnosis (other comorbidities, if any).
- Diagnosis system: ICD 10. (International Classification of Disseases version 10)
- Therapy: drugs given: name, dosage, amount, manner of usage.
- Related Recipes premises electronically (e-prescribing).
- Action: medical action is given, for example Injectable: drug name, dose, mode Injectable (IV, IM, SC, IC).
- Investigations: Laboratory, Radiology (X-rays, ultrasound, CT Scan, MRI).
- Associated with E-Lab., E-Imaging.
- Suggestions: (if any).
- Date control.
- Date and time of the examination is completed.
- Name and signature of a doctor.
Types of Medical Records:
1. Outpatient Medical Record.
2. Inpatient Medical Records.
3. Special Medical Record:
a. Localist status (Patient Surgery).
b. Patient Obstetrics and Gynecology.
c. The patient’s eyes.
d. ENT patients.
e. Mental Patients.
f. Patients Teeth and Mouth.
Medical Record Usability:
1. As evidence of the record has been inspected, treatment, action, investigation, advice to patients.
2. As the patient’s personal data and confidential.
3. Evaluation of treatment, both now and in the future.
a. Secrets of physician office.
c. Purposes of the investigator when requested / needed.
e. Since the last treatment, must be kept within 5 years