1.0Top To Highhttps://toptohigh.comtripmegamarthttps://toptohigh.com/author/tripmegamart/rich600338<blockquote class="wp-embedded-content" data-secret="d3CgdVQ8jL"><a href="https://toptohigh.com/the-medical-record/">The Medical Record</a></blockquote><iframe sandbox="allow-scripts" security="restricted" src="https://toptohigh.com/the-medical-record/embed/#?secret=d3CgdVQ8jL" width="600" height="338" title="“The Medical Record” — Top To High" data-secret="d3CgdVQ8jL" frameborder="0" marginwidth="0" marginheight="0" scrolling="no" class="wp-embedded-content"></iframe><script type="text/javascript"> /* <![CDATA[ */ /*! This file is auto-generated */ !function(d,l){"use strict";l.querySelector&&d.addEventListener&&"undefined"!=typeof URL&&(d.wp=d.wp||{},d.wp.receiveEmbedMessage||(d.wp.receiveEmbedMessage=function(e){var t=e.data;if((t||t.secret||t.message||t.value)&&!/[^a-zA-Z0-9]/.test(t.secret)){for(var s,r,n,a=l.querySelectorAll('iframe[data-secret="'+t.secret+'"]'),o=l.querySelectorAll('blockquote[data-secret="'+t.secret+'"]'),c=new RegExp("^https?:$","i"),i=0;i<o.length;i++)o[i].style.display="none";for(i=0;i<a.length;i++)s=a[i],e.source===s.contentWindow&&(s.removeAttribute("style"),"height"===t.message?(1e3<(r=parseInt(t.value,10))?r=1e3:~~r<200&&(r=200),s.height=r):"link"===t.message&&(r=new URL(s.getAttribute("src")),n=new URL(t.value),c.test(n.protocol))&&n.host===r.host&&l.activeElement===s&&(d.top.location.href=t.value))}},d.addEventListener("message",d.wp.receiveEmbedMessage,!1),l.addEventListener("DOMContentLoaded",function(){for(var e,t,s=l.querySelectorAll("iframe.wp-embedded-content"),r=0;r<s.length;r++)(t=(e=s[r]).getAttribute("data-secret"))||(t=Math.random().toString(36).substring(2,12),e.src+="#?secret="+t,e.setAttribute("data-secret",t)),e.contentWindow.postMessage({message:"ready",secret:t},"*")},!1)))}(window,document); /* ]]> */ </script> The medical record is one of, if not THE, most important documents within the delivery of healthcare services.It is what tracks the course of a patients care. It allows medical providers to review a patients medical history as well as plan a course of care for the future. It is a communication tool that not only provides clinical data regarding a patient’s current and past medical history, but is also used in the reviewing and reimbursement of insurance claims, and to review utilization and quality of care. The Contents of a Medical Record * Face sheets, encounters for each visit * Vital Signs * Physician’s orders * History and Physical forms * List of Medical Problems * Medication Lists * Progress Notes * Discharge Summary * Authorization Forms * Diagnostic Testing * Laboratory Testing * Operative Reports * Pathology Reports Documentation Documentation is the most critical function regarding keeping accurate medical records, as it records all of the important details and facts regarding a patient’s care. Documentation: is legal documentation includes a patient’s medical history chronologically documents a patient’s care allows physicians to plan and evaluate a patient’s care provides continuity in care allows all physicians involved in a patient’s […]