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Medical records

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universityof embu
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Medical records • • Introduction Medical record refers outline used in medication that contains the history of a single patient within one health care provider (Yi et al., 9) . This presentation will involve the medical components, steps of making correction in medical record electronically, disposal of medical records, legal way to release medical records and ethical dilemma when dealing with medical records. Components of medical records • • A medical records contains the patients demographics. It includes the patients name, sex, age, birthday, race, occupation, address, marital status, next of kin and phone number. • Secondly, another significant component of a medical record is the financial information. This components has information about the insurance payer name, address and phone number, policy number, responsible party name, employer phone number and patient connection with the insured. • Components of medical record • Moreover, a medical record needs to have consent and authorization forms. • The form must have consent for treatment where the medical professional must provide consent for any unusual medical procedures and they need to inform the patients information so that they can make informed decision about their care (Dubovitskaya et al., 650). • The medical records contains the diagnosis and possibility of recovery, recommend best treatment, the risk involved in treatment, possibility of success of treatment, challenges and time i ...
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