The Importance Of Health Record

810 Words 4 Pages
Document, document, document is the word of the day for the topic of patient health records. Each and every time a patient is checked in at an ambulatory center, admitted into an acute care facility or has an encounter with a health care professional or support staff there should be a corresponding electronic or hand-written footprint of the meeting with the appropriate accompanying narrative documented into the patient’s health record. This action protects the patient, the care provider and the facility itself.
Therefore, the initial encounter is arguably the most important. This is because the primary health record is established when the patient first starts to share their demographics, health history and current symptoms along with
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Documenting with the person says as well as what they see may the difference of life and death. One example of this is when an active stroke victim presents to the emergency department. If the registration staff sees the patient’s face is drooping and hears their speech is slurred while entering in their data they can spring into action to assist the patient which improves the patient’s outcomes. This is because “stroke is a medical emergency and major cause of death and disability, however, its effects can be reversed for some patients if treatment is swift” (Sanders, 2013, p. 34). Additionally, if the patient’s file is properly documented in that instance future care is also improved. This and other historical information documented in the primary file critical to patient care because clinical providers are provided with the patient’s written story. The primary record or written story may indicate to the clinician that the patient previously had a stroke and when the patient presents again the same or similar symptoms their care is improved because valuable time is not wasted testing to rule out other possible …show more content…
Health information technology and management (1st ed.). Prentice- Hall
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O 'Malley, A. S., Draper, K., Gourevitch, R., Cross, D. A., & Scholle, S. H. (2015). Electronic health records and support for primary care teamwork. Journal Of The American Medical Informatics Association, 22(2), 426-434 9p. doi:jamia/ocu029
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