in this assignment, you will explain the different forms required that make up t
ID: 456813 • Letter: I
Question
in this assignment, you will explain the different forms required that make up the patient’s record, from the time a patient is admitted to an inpatient facility, to the time they are discharged. We are assuming they are there for a minor surgical procedure. There are several items to be included in this paper. There are three large categories: Administrative Information and Demographic, Financial, and Clinical Data, Clinical Information, and Clinical Observations. All information for the paper should come from these large categories.
Explanation / Answer
The world health organisation has given some guidelines on medical recording particularly in clinical area. The administrative Informations required are as follows
1: Name
2: AGE Including date of birth
3: Gender
4: Address
5: Mobile phone number
6: E mail ( Required from Inpatients only)
7: Medical record Number
Demographic Information
1: Gender ( Already mentioned in adminstrative)
2: Ethnicity( Collecting information on these may raise ethical issue)
3: Degree of illness ( High BP, Average, Low)
4: Income status ( Patients may not ready to share it but based on the type of insurance card it can measure)
Financial data
1: Income (comes under demographic)
2: Type of insurance cards is using
Clinical data should include
1: Record on patients health
Which should include Height, weight, temperature, Bloop Pressure, BMI,
2: Type of diseases he receiving
3: category of doctors he is going
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