TYPES OF HEALTH RECORDS

Types of health Records
Andre Cornwall
Westwood College

TYPES OF HEALTH RECORDS

Types of Health Records There are all types of Health Records documentation available; it may be paper or electronic. The first type of documentation is Acute Care. Acute Care is the foundation for content and practices for other healthcare settings, like Clinical Data, Administrative Data, Consents, Authorizations, and Acknowledgments. Next is Specialized Health Records like Emergency Care, Ambulatory Care, Ambulatory Surgical Care, Long-term Care, Hospice Care, Behavioral Healthcare, and Rehabilitation Services Documentation. Paper or Plastic? That is what the grocery store would ask you, but the times are changing and so is the Healthcare field. Now you do not have the choice in how your information is documented in the Medical Record. There are still paper records but workers of the Health field find them self-scanning paper information into the EHR’s system. Let’s describe the different documentation, may it be paper or electronic. Clinical Data is all the information one will get for a patient when they are admitted to the hospital. While the patient is admitted other info will be add to the patients chart: * A patient’s medical history, like the Chief complaint, Present illness, and Review of systems. * The reports of consulting physicians which is the opinion of another physician. What I call “Get a second opinion”. * A discharge summary, the release for the hospital.
Administrative Data is the patient’s demographics. It tells the patient’s name, facility identification number, address, telephone number, date of birth, gender, race, marital status, next of kin, date and time of admission, and the hospitals name, address, and telephone number. Let’s not forget one of the most important info is the insurance information like