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Group 1 Hospital Dentistry 1

Medical records document a patient's medical history and care over time within a healthcare provider. They contain biographical data, illnesses, treatments, preventative care, and details of services. Medical records are important to ensure continuity of care for patients and have legal purposes like defending malpractice claims or injuries. They allow doctors to understand a patient's history and create treatment plans.

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Torrecampo Yvette
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43 views5 pages

Group 1 Hospital Dentistry 1

Medical records document a patient's medical history and care over time within a healthcare provider. They contain biographical data, illnesses, treatments, preventative care, and details of services. Medical records are important to ensure continuity of care for patients and have legal purposes like defending malpractice claims or injuries. They allow doctors to understand a patient's history and create treatment plans.

Uploaded by

Torrecampo Yvette
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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GROUP 1

HOSPITAL DENTISTRY 1
Recent improvements in patient healthcare are the
result of many factors: scientific breakthroughs,
medical innovation, and technological advances.

Medical records fall into the last category; they are a


portal through which a physician and other medical
staff can step into the history of a patient to learn
about prior care, understand current diagnosis and
status, and subsequently create a treatment plan.
What Are Patient Medical Records?

The terms medical record, health


record, and medical chart are used
somewhat interchangeably to describe
the systematic documentation of a
single patient's medical
history and care across time within one
particular health care provider's
jurisdiction.
Medical records involve a variety of information about a patients
health history and personal habits, including:

1. Significant illnesses and medical conditions, including


documentation on lab findings, diagnosis, and treatment
plans.
2. Biographical data including any history of alcohol use, drug
abuse, and smoking, in addition to physical exams, allergies,
medications, and any adverse reactions.
3. Preventive therapies such as immunizations and screenings.
4. Paperwork to document services performed by medical
professionals including dates, times, attending medical
personnel, admittance and discharge reports, prescriptions,
and any other related medical and lab reports.
Why Are Medical Records Important?

1. To ensure continuity of care for the patient.


2. For legal purposes
Ex: the patient pursues a claim following a a road
traffic accident or injury at work
3. For health professionals
Ex: for defending a complaint or clinical negligence
claim

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