Question

In addition to providing the basis for documenting past medical care, high-quality data and information is used in a patient's record to base current and future medical care.

• Name another major function of the data contained in medical records and explain your selection

Your response post should have a minimum of 150 words.

Answer 1

Medical records are documented evidence of the patient’s health history and current health status. It serves as a key source of information for the physician while treating the patient. The complete case history in a medical record includes,

• Demographic data
• Personal and medical history
• Patient’s family history
• Patient’s social history

The three functions of patient health records or medical records are,

1. The patient health record provides an accurate health history and medication history of the patient
2. It is considered as the primary document of communication among different healthcare providers at different times
3. The patient health record provides all the necessary information about the patient health history and demographics during emergencies

The social history of patients include, the information about their lifestyle, habits of consuming alcohol, smoking, drugs of abuse and marital information. This information is necessary as these factors influence the health of an individual directly or indirectly.

The medical records also contain the objective information. It is provided by the physician or provider. For example, the heartbeat, body temperature, diagnosis of the disease are the objective information.