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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