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Medical Records Evaluation and Proposal

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Running head: Medical Records Evaluation and Proposal
Medical Records Evaluation and Proposal
You’re Name
You’re Professors Name
Course Title
Submission Date

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Medical Records Evaluation and Proposal 2
Medical Records: Collects Patient Form
In addition to the collected medical records collected during our interview, additional
health care patient records have been obtained and evaluated from the text material as well as a
medical facility and the results from the internet. Admissions record, Social Services
admits/discharge Reports, and Advanced Care Planning have been physically attained. However,
researchable health information records reviewed includes the following which has obtained,
analyzed, and evaluated from our internet discoveries:
I. Health Information Release Authorization Form
II. Medications Records
III. Medical History Forms
IV. Medical Chart, i.e. Vitals, Pain, Intake, and Output Records
V. Food/Nutrition: i.e. Food Journal, Daily Fluid Intake, and Nutrition Log
VI. Notes: i.e. Medical Diaries, Journals, and Logs
Comparable Health Information Reports
Checklist Core Elements (Self-Created) Comparable Health Medical Report
Internal patient identification (medical
record number)
Patient Name
DOB
Gender
Race
Ethnicity
Address
Telephone number
Alias/previous/maiden names
Social security number
Facility identification
Universal patient identifier (not yet
established)
Account-visit number
Admission encounter-visit date
Discharge departure date
Encounter-service type
Encounter-service location
Encounter primary physician
Health record
Billing number
Patient Name
DOB
Social security number
Race
Address
Telephone number
Facility Identification
Admission Date/Time
Discharge Date/Time
Service Rendered
Attending Physician
Disposition
Medical Notes

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Medical Records Evaluation and Proposal 3
Patient disposition
(Sayles, 2013, p. Ch.vii)
Patient Information Recommendation
Evaluating the different forms and formats of collected healthcare information was
straight forward to determine, that each form requires specifics data in addition to the formalities
of patient information tracking and identifications. For example, all documentations observed
included unified system retrieval information in the form of alphanumerical, (example: LP0589),
the First and Last Initial and DOB referencing, general construct of visited evaluation, as well as
physician’s commentary notes and recommendations. However, as mentioned, each form is
tailored to elicit information for that specified visitors, thus, although observable information
will be unified, each document is completely will outlined for ease of diagnosis: increasing
quality of care and reducing significant organizational risks.
Proposed HER Medical Record
Developing a specified form requires specified sections within the functional medical report
As the HIM manager, designing a form as part of the new electronic health record
implementation must consist of the above core collected data, including the following basic
patient identification methods, alpha, numerical, and/or a combination thereof. The following
form must consist of:
I. Patient Centered Records
a. Admission Date/Time
b. Patient Name
c. DOB
d. Social security number
e. Telephone number
f. Patient’s Medical History
g. Diagnoses
h. Medications
i. Treatment Plans

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Medical Records Evaluation and ProposalYou're NameYou're Professor's NameCourse TitleSubmission DateMedical Records: Collects Patient FormIn addition to the collected medical records collected during our interview, additional health care patient records have been obtained and evaluated from the text material as well as a medical facility and the results from the internet. Admissions record, Social Services admits/discharge Reports, and Advanced Care Planning have been physically attained. However, researchable health information records reviewed includes the following which has obtained, analyzed, and evaluated from our internet discoveries:I. Health Information Release Authorization FormII. Medications RecordsIII. Medical History FormsIV. Medical Chart, i.e. Vitals, Pain, Intake, and Output RecordsV. Food/Nutrition: i.e. Food Journal, Daily Fluid Intake, and Nutrition LogVI. Notes: i.e. Medical Diaries, Journals, and LogsComparable Health Information Reports Checklist Core Elements (Self-Created)Comparable Health Medical ReportInternal patient identification (medical record number)Patient NameDOBGenderRaceEthnicityAddressTelephone numberAlias/previous/maiden namesSocial security numberFacility identificationUniversal patient identifier (not yet established)Account-visit numberAdmission encounter-visit dateDischarge departure dateEncounter-service typeEncounter-service locationEncounter primary physicianPatient di ...
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