Record Components Documentation Requirements Medical Records Essay Example

Record Components Documentation Requirements Medical Records Essay Example Record Components Documentation Requirements Medical Records Paper Record Components Documentation Requirements Medical Records Paper Essay Topic: Medical When a new patient comes to a doctor’s office bearing medical records, there are a number of things that the office wants to make sure that the patient has with them. This holds doubly true when dealing with an OB/GYN patient who is experiencing a second pregnancy and who had problems with the first pregnancy. When the patient comes in, the doctor and medical records manager wants to assure that the patient has at a minimum, the doctor’s dictation, the tests that the doctor ordered regarding the health of the mother and the baby, the hospital records regarding the first pregnancy, basic medical information, and the post natal information regarding her first pregnancy. The doctor’s dictation is important because it shows the visit to visit issues that occurred and how each was resolved. The dictation allows the new doctor to see the â€Å"train of thought† of the previous doctor in order to see the issues that came to light and what was done to resolve them. This gives the new doctor valuable insight into how this particular patient’s body operates, and can be valuable in keeping problems from occurring in the future. The tests that the doctor ordered are also important. This allows the doctor to get a sense of the health of the patient and to establish a baseline by which to conduct further assessments. It also gives the doctor a sense of the idiosyncrasies of the patient and to show what numbers and results are considered normal for the particular patient. It also gives the doctor an idea of what issues were discovered and what tests were necessary to diagnose and treat the problems regarding the first pregnancy should there be problems with the second. The hospital records are paramount in determining the doctor has all the information that he needs to have an accurate picture of the patient and her health. By having these records, there is a sense of the urgency that the first pregnancy had as well as any and all problems that were occurring as the patient was giving birth. Without these records, when the patient came time to deliver, there might be problems to which a solution had already been found and a potential litigious situation can be avoided. Basic medical information is probably the most important information that a doctor needs. This establishes the baseline health of the patient in order to give the doctor a sense of the history of the patient and if there are any unnecessary gaps in the wellness of the patient. For example, does the patient have her shots, is she current on Pap smears, mammograms and other tests that are important to the baseline health of the patient. Finally, post-natal information is needed in order to determine what, if any issues the first child had post-natally. By having this information, the doctor is aware of any and all issues that may arise in the post-natal health of the child and can be prepared to treat it should it become necessary. Additionally, there would be test results that would show any genetic predisposition to disease, and the doctor would have this information in order to help the patient make an informed decision regarding her reproductive health should it become necessary. Making sure that the patient has all the records needed should not be the sole responsibility of the patient. The doctor’s office does have an obligation and a responsibility to assure that all applicable records are obtained, should the patient have neglected some seemingly trivial piece of information that ends up being a vitally important piece of the puzzle. JCAHO, (2009). Standards frequently asked questions. Retrieved June 15, 2009, from JCAHO Web site: jointcommission. org/Standards/FAQs/ Montauk, S. L. (1998). American family physician. Retrieved June 15, 2009, from AAFP Web site: aafp. org/afp/981101ap/montauk. html