1-4 Journal: Health Records - Critical Clinical Assignment (Essay Sample)
Explain the different types of health records and how they are used, supporting your response with relevant sources. Examples might be administrative records or clinical records.
Explain how information is structured in an EHR versus in a paper record, supporting your response with relevant sources. Not all information is structured the same, and there may be differences between a paper record and an EHR.
Your answers should be supported with relevant sources and should be in APA format.
Medical records are used to record and store critical clinical information and can either be on paper or digital. MariniÄ (2015) discusses that the health records ensure the proper health monitoring, treatment, and planning. The documentations include the consultation notes that the physician records during an appointment. Also, the admission records that contain the information regarding the reasons for one’s admission to the hospital. Another type of health record is the clinical documentation that includes personal information about the patient, lab results, treatments, and X-rays. Additionally, any correspondence relating to the care of the patient between them and the doctor or with other physicians are also part of the clinical records. The clinical records also have information concerning any transfers and details from the previous doctor if any, and patient’s history (Hayrinen, Sranto, & Nykanen, 2008). The discharge records are another kind that contains details of the patient’s treatment results and indicate if there are any further care or follow-ups are necessary.
The structuring of the electronic health records (EHR) varies from that of the paper-based record. Acc...
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