Question

Select one of the following:

• Inpatient Records
• Outpatient Records
• Physician Office Records

Based upon your own practice setting, or your desired practice setting, discuss the key components of the patient record. What makes a thorough and high-quality patient record in your setting?

Answer 1

Outpatient Records

At my own practice setting, we maintain 2 copies of outpatient records, one with the patient and the other one we keep it at our clinic. They contain a unique number . The purpose of maintaining 2 copies is when a patient could not come to the clinic, but needs medical advice, then we ask the patient to tell us the unique number that is given to their record. Then we can go through her record that lies with us (second copy) and can give the patient the appropriate advice.

KEY COMPONENTS OF A OUTPATIENT RECORDS:

Patient Identification Number - This code is patient specific which lies on the first page of the record.

Patient Details: This includes Name, Age , Sex, Address, Contact number.

Patient's Medical and Surgical History : This includes patient's comorbidities like hypertension, diabetes, hypothyroidism etc.

Patient's Medication History : This includes the medications he or she has been using or used in the past.

Patient's Social History : This includes his or her drinking and smoking habits, lifestyle .

Patient's Allergic status: This includes information if patient is allergic to any drugs/ substances.

Previous Prescription: This includes the patient's past prescriptions.

Present Complaint : This includes the complaint with which he/she came to the hospital.

Lab tests and results: This includes the tests ordered and their results.

Treatment : This includes the drugs prescribed along with dosage, route of administration, frequency and duration of therapy, possible adverse effects with the drugs.

Referred to : This includes the name of the doctor, the patient has to consult.

Review date : This includes the followup date on which the patient has to come.

Signature : This includes signature of the prescribing doctor.

These are the fundamentals to maintain a high quality record. It requires effort of the prescriber to collect the quality information from the patient and also the patient to give the correct information to the prescriber.