Medical Records Evaluation and Proposal

Feb 3rd, 2012
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National American University - Rapid City
Course: Intro Health Information Mgmt and Health Care SU14
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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:

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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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