Unit 2 IP

Record Components Documentation Requirements - Medical Records

Name of University

Name of Student

Date

Abstract

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 ed 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 train of thought ' of the previous doctor in 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 ed 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...