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Medical Records


Management of health information or medical records, is file / record patient medical information such as medical history, care or care received, test results, diagnosis, and medication taken.
The process of conducting a medical record begins at the time the patient is admitted to the hospital, followed by the recording of the patient's medical data by a doctor or dentist or other health personnel who provide direct health services to the patient. As long as the patient gets medical services at the hospital, and continues with the management of the medical record file which includes the organization of storage and file issuance from the storage area to serve requests / loans because the patient comes for treatment, is treated, or for other purposes.


The use of computarization systems in the implementation of medical records is very helpful in the process of processing medical data of patients as well as expenditure of information regarding the effectiveness and efficiency of health services and the extent of health service coverage by a health service agency in providing health services to patients. So that the data and information produced are fast, precise, accurate and up to date.

 So, What includes the medical record?

1 Personal Identification Information
Each medical record must have specific personal identification information, such as a social security, state, or government-issued identification number in order to tie the record to the correct patient. Most records will have facility-specific identification as well, but all must have detailed personal identification.


2.Medical History
Everyone has a medical history, even if they have never been to a hospital and never had their immunizations. How is this so? This is so because not having these is a part of the medical history as well. Patient medical history includes all diagnoses, medical care, and treatments, allergies, and even the lack of need for medical care. This information tells medical personnel a great deal about your current symptoms, such as, whether an illness is acute or chronic, seasonal or situational.

3. Family Medical History

Information about family members' health is an important part of your medical records because some health concerns are genetic. Knowing that a distant cousin had hangnails may not be important, but knowing that the patient’s grandmother had some form of heart condition or cancer certainly is.
4. Medication History
What we ingest, whether it is prescribed, over the counter, herbal, or illegal, is an important piece to our medical puzzle. A medical professional needs to know about herbal, over the counter, home remedies, prescription medicines and even illegal drug use because of the way these can affect our health not only immediately, but over time.


5. Treatment History
Knowing what treatments have been given, whether they worked, and which have failed is significant information for the provider to have. This information saves time and money in giving appropriate treatments or therapies.


6. Medical Directive
Most patients who have had any treatments at a hospital have a medical directive or living will. This document is kept on file and tells the treatment team the wishes of the patient in the event that they are unable to speak for themselves regarding their medical care.





Roro Semanding  106218045



Sources:

Medical Records Content :
https://www.verywellhealth.com/importants-parts-of-a-medical-record-2317249


http://www.rmch.org/getpage.php?name=medical_records

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