What are the components of medical health records?

What is a medical record? 

health policy making, Whenever you visit your doctor for a check-up, they create a document in which there are details about your reason for your visit. Records that are created in hospitals for patients are known as medical records. A medical record is a systematic documentation of your medical history. It includes “notes” that are created by healthcare professionals such as doctors. This record contains observations, administration of drugs and therapies, x-rays, blood test reports, etc. These records are important for both you and your doctor. Medical records are things written such as paper notes, image films, and digital records. 

What are the main components of medical records?

Your medical record is an important document that contains information about your case history in chronological order. The health records which are the written notes and the electronically stored data all a part of your medical records. Here are the components of medical records: 

An aggregation of important data 

Your data is collected and kept securely by healthcare providers. Generally, this data is stored electronically in EHR software. There are different types of data collected by the software such as : 

  • Your details like age, nationality, gender, and sex. 
  • Social activity such as profession 
  • Details about genetics 
  • Medical diagnosis and history 
  • Details of vaccinations doses got till now 
  • List of allergies and illnesses 

Your Medical history  

Every person in this world has a medical history, even people who have never been to the hospital. Whether it be a small issue or a big disease, it all comes under medical history. Medical history comprises of the following things: 

  • Past diagnosis
  • Medical care 
  • Allergy records 
  • Past treatments 

The medical history helps doctors to plan future treatments and take decisions about what medication to offer. This also affects your choices of health policy making choice. 

Treatment history  

This plays an essential role in your medical records and works as a directive for doctors. A treatment history encapsulates details of every treatment that you have been through. It includes all surgeries and procedures that you are subjected to till now. It also tells the efficacy of the treatment on your body. It also includes the previously taken medications and how well they worked on your body.  

Family medical history  

Details about your medical history are important criteria as some health conditions may be genetic offering no control. Such conditions give no scope for prevention as the disease is genetic. Such diseases are generally critical illnesses like cancer and diabetes. Although, sometimes people are not aware of the fact that the disease is running in their family and getting transferred from one generation to the other one. 

Prescriptions and e-prescriptions 

When you visit the doctor, they give you a prescription that holds details about the medicine and the dosage. This prescription is also a part of the medical record. It authorizes the patient to purchase the medicine from the pharmacy store. It contains the name of the drug that the patient should intake. Ever since the pandemic hit, online consultations have been going on. In such cases, the doctors provide e-prescriptions (electronic prescriptions). The EHR system is the system used by doctors to prescribe drugs to patients. This software makes prescription making so easy. It is therefore quite useful for hospitals. 

Lab results  

A lab test is medical testing that utilizes some kind of body sample like a sample of blood, urine, saliva, tissues, etc. Lab tests help to detect symptoms of disease or illness, evaluate the progress of the treatment, run diagnosis of a disease, monitor the course of disease over time, and help the doctors to plan treatment. Moreover, lab tests must be done regularly to keep checking whether the body is running properly or not. From the perspective of doctors, it helps them plan the best healthcare plan for doctors. 

Final Note: 

A medical record is a systematic documentation of your medical history. health policy making This record contains observations, administration of drugs and therapies, x-rays, and blood test reports. Medical records are things written such as paper notes, image films, and digital records. The main components of the medical records include an aggregation of important data, your medical history, treatment history, family medical history, prescriptions and e-prescriptions, and lab results. The medical records are important for future healthcare providers, it is also important for the present treatment and overall care of your records. Another benefit is that in case the patient has a really bad side-effect of the treatment, then they can even go for legal cases.  A medical record is an official record of the treatments and medications that the patient gets. Another important application of medical records is getting insurance claims. Insurance claims need your medical records and hospital bills to process. The other use of medical records is for medical research purposes. 

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