Patient Health And Technology Essay

659 words - 3 pages

The quality of healthcare an individual receives can all boil down to how well a patient’s record are documented and the ability to access that patient’s information. The ability to access and locate vital health care information can be life or death for a patient. The ability to locate vital patient healthcare information is crucial to the assessment of patient care.
A patient’s record can be comprised of five main parts consisting of medical history, lab results/diagnostic results, problem list, clinical notes, and treatment notes. The medical history includes patient demographics, chief complaint (reason why patient is seeking care), history of present illness, past medical history, ...view middle of the document...

Allergies will list all the patient’s known allergies. Medications contain information regarding a patient’s current medication(s). Review of systems provides information on how the patient is feeling and the symptom that the patient is experiencing from head to toe. Physical exam information contains information from the practitioners’ physical exam.
Lab/diagnostic results consist of initial lab results consisting of a basic metabolic panel and complete blood count and additional parameters specific to diagnosis and medical conditions, as well as additional results of diagnostic testing. The problem list consists of working diagnosis that matching the patient’s signs and symptoms. The clinical notes consist of the clinical notes from various practitioners that have been involved with the patients care. The patient’s treatment notes include medications, prior surgical history, documentation of services (includes radiation therapy, physical therapy, occupational therapy, respiratory therapy and nutrition.
As technology grows, so does healthcare advances. These healthcare advances result in technological healthcare systems, electronic patient records and improved access to patient data. The capabilities of...

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