IN MANUAL AND ELECTRONIC BASIS
A Research Proposal submitted to
Ms. Bettina Joyce Ilagan
Department of Languages and Mass Communication
College of Arts and Sciences
SCIENTIFIC REPORTING AND
EMERSON C. RODIL
JAMES IAN M. CORSAME
DENNIS R. AGUSTIN
JORELL KIEFFER V. BALINBIN
October 14, 2010
Hospital medical records traditionally have been maintained in bound ring file folders. However, many settings are now utilizing electronic medical records. They can found at nursing stations throughout the hospital. The patient’s name, date of birth, room number, hospital identification number. The top cover of the folder will list any alerts associated with the patient. These alerts might include: name alert (two persons on the same ward with same/similar names), specific drug allergies, infectious disease alert (TB, Hepatitis A, HIV positive), or infection control alert (requires gown, gloves, mask, booties to enter room).
The medical record is divided into numerous sections typically including: demographic data, discharge summary, admitting history and physical health and problem, physician progress notes, consultations, pharmacy notes, dietary notes, laboratory, pathology, and x-ray/radiology reports, operative reports, physician orders, and nursing notes. Individual services (e.g., cardiology, pulmonary, Gastro Intestinal) may also have their own sections. All appropriate sections should be reviewed prior to evaluation of the patient so that the patient’s current status may be determined.
In most cases, the optometrist will chart within the consultation section of the medical record. Many hospitals will have specific preprinted consultation forms that are to be filled out and placed within the consultation section of the medical record. In other cases, a consultation note may be written in the physicians’ progress note section. Notes... [continues]
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