What is right patient chart in medication?
Answers
A medical chart is a complete record of a patient’s key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.
What kind of information comprises a medical chart?
Ideally, medical charts contain records of every medically relevant event that has happened to a patient since birth. Events include diseases, major and minor illnesses, and growth landmarks. A medical chart should give any clinician an understanding of everything that has occurred previously to the patient. This is crucial to help healthcare providers diagnose current disease states.
A medical chart includes:
Surgical history
(e.g., operation dates, operation reports, operation narratives)
Obstetric history:
(e.g., pregnancies, any complications, pregnancy outcomes)
Medications and medical allergies
Family History
(e.g., immediate family member health status, cause of death, common family diseases)
Social History
(e.g., community support, close relationships, past and current occupation)
Habits (e.g., smoking, alcohol consumption, exercise, diet, sexual history)
Immunization Records
(e.g., vaccinations, immunoglobulin test)
Developmental History
(e.g., growth chart, motor development, cognitive/intellectual development, social-emotional development, language development)
Demographics
(e.g., race, age, religion, occupation, contact information)
Medical encounters
(e.g., hospital admissions, specialist consultations, routine checkups)
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