Medical Records
MEDICAL RECORDS Description also available in video format (attached below), for better experience use your desktop. Introduction · Medical Records are the legal documents providing a chronicle of a patient’s medical history and care · Members of healthcare team that can make entries in medical records are o Consultants o Nurses o Technicians o RMOs · Medical records includes a variety of notes entered over time by the healthcare professionals Uses, Components, Labelling, Issue, Functions & Process of Medical Records · Uses o To document the course of illness & treatment o Communicate between attending doctor and other healthcare professionals o Collection of health statistics o Legal matters & Court cases o Insurance cases · Components o Identification summary sheet o Consent for treatment o Legal documents o Discharge summary o Admission notes o