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, family history, social history, allergies, medications, review of systems and physical exam information. Patient demographics information consist of name, birth date, address, phone number, gender, race, marital status, attending physician, insurance information, pharmacy name, pharmacy phone number and religious preference. Chief complaints consist of the reason(s) why the patient is seeking care. History of present illness list the history of the current illness beyond that of the chief complaint and listed in chronological order. Past medical history list the past and current medication conditions and includes past surgical history. Family history includes descriptions of age, living status (dead or alive), and presence or absence of chronic medical conditions in immediate family members (parents, siblings and children). Social history documents a patient’s lifestyle and characteristics. This also includes the use of alcohol, tobacco, drugs and documents, type, amount and frequency. This is also where patient’s dietary habits, exercise, frequency of caffeine products, education, occupation, marital status, number of children, sexual practices and preference,