Health Record Worksheet Essay Example for Free

Health Record Worksheet Essay In 150 to 350 words, explain the importance of the health record. Support your explanation using your assigned readings. The importance to health records is that it is easier to treat a patient if you already have the history of the patient illnesses and what medications have helped in the past as well as it will tell them anything they are allergic. They are also important for you don’t have to retake the same test over again if you already have it on file at the hospital you went too. Now with the electronic health care they are heping to make the paients experience better for them with less wait time and questions. Also with the electronic health records it helps the doctor to be reminded of when a new test needs to be done or when a prescription needs to be filled as well. I think that all health records are good because your doctor can go back and see what you were treated for and what has helped you in the past that can help you now.   Use the following table to identify and list at least five key components of the health record. Additionally, include a 50- to 100-word description of each component. Support your descriptions using your assigned readings. Component of the health record Description Adminerstrative system component This where the patient gets registered, admitted, and discharged this information is very important without this in health records it would make it a lot harder to get the patient seen. This is why it is a key component to health care because without this it wouldn’t run as smoothly. Laboratory system component This is where the doctor can put in orders to get lab work done then someone will bring the sample to the lab to get processed. Then later the doctor can find the results and figure out a diagnosis of the patient or order more labs to get done on the patient. Radiology system component This is where the doctor can order a xray of a patient and then the patient gets sent down to Radiology to get xrayed. Then the radiologist will send the pictures to the doctor after they are processed. The doctor will tell the patient why they are in pain and the next steps for them. Pharmacy system component This is where the doctor can order perscriptions and send them to the pharmacy without writing out a prescription and giving them a paper to bring to pharmacy. Also will help make sure that there are no forgery with any of orders. That way the patient doesn’t lose it as well. Clinical documentation This where the patients information goes so it is easily found by the doctor to access it. Also is where the description of the events that happened of each visit with the patient and what has worked and what did not work as a solution. Also can find the patients contact information here. Use the following table to identify and list at least five structured coding systems. Additionally, include a 50- to 100-word description of each system. Support your descriptions using your assigned readings. Structured coding system Description International classification of diseases  this would be different coding they use between other countries and the United States. This is when I believe a patient comes to America with the disease already in them so they talk about it to others they use a code instead of just plainly saying it out loud in front of the patient. Diagnostic and Statistical Manual of Mental Disorders This is what doctors use to label someone with a mental disorder whether it was from birth or from a substance abuse. Every patient would have a code with them instead of labeling them they just used codes to tell them apart in a hospital. Also easier to keep track of who is who. Current procedural Terminology This is when you have a patient in the examing room and need to tell your nurses what is happening and what needs to be done so they use code names instead of the regular terms so it does not scare the patient they are working on. Also makes it so there is less to say.