Bill Sugg Valley County Health Systems
Discuss the importance of maintaining a proper medical record
Good record keeping is an essential aspect of healthcare department and it is one of the important parts of nursing because it contributes to the circulation of information amongst the different teams that are involved in providing treatment to its patient and proper documentation also ensures the matter of professionalism and it provides you with the proof of the improvement of practices.
The staff of Bill Sugg of Valley county health systems says that medical records are defined as the combination of both self-reported patient information and a physician's notes that are used for providing the patient with the diagnoses, care, and treatments. These also involve a variety of information about a patient's health history and personal habits that also includes:
• The medical condition of a patient
• Biographical data that include the history of alcohol use, drug abuse, and smoking, and in addition to the physical exams, it also includes the allergies, medications, and any adverse reactions.
• Contains the list of Preventive therapies
• It also involves the Paperwork that is performed by medical professionals
What are the components of maintaining a good medical record?
Bill Sugg Valley county health systems have determined the things that need to be included in the patient’s medical record, which includes:-
• Nursing records/progress notes
• Laboratory orders and reports
• Handover sheets and admission
• Medical records
• Vital signs of observation charts
• Medication charts
• Discharge and transfer letters
• Patient’s assessment forms
What is the significance of keeping a good medical record?
Certain factors determine the importance of keeping a good medical record, which includes:-
• Better record-keeping can help in establishing proper communication of information between the members of the multi-professional team.
• It also plays an important role in supporting clinical audit, research, performance planning, and allocation of resources
• It also supports the delivery of services among its patient
• Bill Sugg Valley county health systems say that maintaining a proper medical record also helps in making an effective clinical judgment.
• It also helps in improving the accountability
• It also helps in identifying the risks, and it also enables the early detection of complications
• Helps to address complaints or legal processes
• It also makes the continuity of providing care easier
Thus, a medical record plays a very important role in the life of the patient and the doctors who are playing an important role in providing them the treatment.