What is the medical term for the following past surgical history term removal of the breast?
During a total (simple) mastectomy, the surgeon removes the breast tissue, nipple, areola and skin. Other mastectomy procedures may leave some parts of the breast, such as the skin or the nipple.
How is medical history typically organized?
Usually, the record will be organized in terms of the temporal sequence of events with the latest admission located at the front of the medical record. Usually, dictation occurs after the patient is discharged from the hospital, possibly from inadequate notes or an incomplete medical record.
Which of the following physical exam findings would be indicative of appendicitis?
The most specific physical findings in appendicitis are rebound tenderness, pain on percussion, rigidity, and guarding. Although RLQ tenderness is present in 96% of patients, this is a nonspecific finding. Tenderness on palpation in the RLQ over the McBurney point is the most important sign in these patients.
What are the common medical terms?
Top 25 medical terms to know
- Benign: Not cancerous.
- Malignant: Cancerous.
- Anti-inflammatory: Reduces swelling, pain, and soreness (such as ibuprofen or naproxen)
- Body Mass Index (BMI): Body fat measurement based on height and weight.
- Biopsy: A tissue sample for testing purposes.
- Hypotension: Low blood pressure.
What shows up on medical records?
Your records also have the results of medical tests, treatments, medicines, and any notes doctors make about you and your health. Medical records aren’t only about your physical health. They also include mental health care.
What are the components to a medical history?
A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.
What are the four parts of a medical record?
However, some unified components exist in nearly every complete medical records.
- Identification Information.
- Patient’s Medical History.
- Medication History.
- Family Medical History.
- Treatment History and Medical Directives.
What is the purpose of medical records?
The primary purpose of a medical record is to provide a complete and accurate description of the patient’s medical history. This includes medical conditions, diagnoses, the care and treatment you provide, and results of such treatments.
What are the uses of medical records?
Medical records provide documentary evidence of a patient’s healthcare information. Though there is universal acceptance of the importance of medical records, there is disparity in its application among various nations and systems primarily owing to the differences in cultural and legal frameworks.
What is the function of health record?
The health record is the principal repository (storage place) for data and information about the healthcare services provided to an individual patient. It documents the who, what, when, where, why, and how of patient care.
What is good medical records?
Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time.
Why is it important to obtain accurate medical records of the patient?
Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time.
How do you maintain medical records?
of medical record Certificates are to be prepared in duplicate and one copy must be kept in the records as office copy which should contain the receipt signature of the patient or the legal representative. All medical records including certificates must be prepared in a prescribed performa.
When should risk assessments be carried out?
The Health and Safety Executive (HSE) says risk should be assessed “every time there are new machines, substances and procedures, which could lead to new hazards.” An employer should carry out a risk assessment: whenever a new job brings in significant new hazards.