07:17 1st February 2018 | Importance of Medical Records

Medical Records Patient Information Doctor's Notes Diagnosis Care and Treatments Consultations Medical Professionals Contact Information Biographical Data Demographic Information Medical Information

Medical records typically consist of self-reported patient information along with doctor’s notes on diagnoses, care and treatments. But there’s so much more to it. We want to help people understand why medical records are important. In doing so, we hope to encourage everyone to share accurate information each time they consult medical professionals.

 

Information Included in Medical Records

Up-to-date medical records generally contain self-reported details such as contact and demographic information, lifestyle habits, medical history, vaccination information, past test results and medical imaging.

 

Contact Information 

1. Name and address
2. Cell phone and telephone numbers
3. Who to contact in case of an emergency (and their contact details)

 

Lifestyle Habits: Biographical Data

• Dietary habits and nutrition
• History of smoking and/or alcohol use/abuse
• History of drug abuse

 

Demographic Information

1. Gender
2. Date of birth
3. Country of birth and ethnicity
4. Marital status
5. Employment

 

Medical Information and History: Self-reported and Documented by Doctors

1. Blood type
2. Family medical history
3. Chronic and other medications
4. Allergies and adverse reactions
5. Major diagnosis: diseases, diagnosis and treatment plans
6. Major medical history: significant past incidents and lab findings
7. Preventative care such as prior immunisations and screenings
8. Family doctor and insurance provider

 

It is not emphasised enough how much healthcare providers need and appreciate this information! All paperwork and electronic documentation that exist should be kept safe by patients and their healthcare providers. Details of medical services should include dates, times, attending medical personnel, admittance and discharge reports, prescriptions and any other related medical and lab reports.

 

Why are medical records really important?

Comprehensive and accurate medical records empower healthcare professionals to treat patients to the best of their ability. Every single available detail is important because all accumulated information can contribute to diagnosis and treatment.

 

With the help of information technology, healthcare could become more cost-effective and facilitate improved patient outcomes.

• Safety can be increased
• Processes can be sped up
• Claims processing and reimbursement can be improved
• Effectiveness of therapies and treatments can be monitored and tracked
• With a growing amount of information, outcome predictions can be made
• From a legal point of few, liability is reduced as a result of increased oversight
• With IT, loss of information, errors and omissions can be significantly reduced
• Accurate documentation of initial assessments and progress improves quality assurance
• Methodical records of symptoms, diagnoses and treatments will greatly benefit the next healthcare professional involved and more importantly benefit the patient

 

The number one reason why accurate, up-to-date medical records are important: THEY CAN SAVE LIVES

 

Challenges Associated with Information Gathering and Distribution

As much as medicine is a science, it is also an art that relies on personalisation. Requesting personal information or delivering uncomfortable news is always challenging. Medical professionals should therefore inspire trust, nurture doctor-patient relationships and make their patients feel as comfortable as possible, all while ensuring them they can trust in doctor-patient confidentiality.

 

ADVICE

It’s not too late to start keeping track of all your medical records. Also, if you have children, start (or continue) logging his or her different doctors, consultations, procedures and surgeries. Also request copies of any reports and results. Reliable records will help doctors to provide the best care for your child.

 

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If you want to book an appointment or have any questions, please don’t hesitate to get in touch:

Email: enquiries@thebridgeclinic.com
Call:    01 631 0092 / +234 (0)1 631 0092
Visit:   66 Oduduwa Way, Ikeja GRA

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