PHS Med Records and Reports Flashcards

Front

What are the purposes of medical documents?

Back

Medical documents help healthcare teams understand a patient’s medical background, give the best possible care, and collectively use and share patient information.

Front

What forms of patient information are included in medical documents?

Back

Medical records and medical reports, which include patient information collected over time and single reports for a test, screening, or procedure.

Front

What are medical records?

Back

Medical records are a comprehensive collection of patient health information and medical history, shared only with authorized parties.

Front

Who are authorized parties to access medical records?

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Providers, patients, authorized caregivers, and insurance companies.

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What personal information is included in medical records?

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Name, age, gender, ethnicity, medical and family history, prescriptions, medication records, medical reports, immunization records, surgeries, and hospitalizations.

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How are medical records shared?

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Shared among multiple healthcare professionals, between different facilities and providers, for insurance claims, with patients, and with caregivers.

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How do patients use medical records?

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For seeing a new provider, keeping personal records, legal reasons, admission to educational institutions, work clearance, and applying for health benefits.

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What are patient forms?

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Documents containing information that goes into a patient’s medical record, filled out by patients or providers.

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What information may be included in patient form data?

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Personal information, chief complaint, current medical conditions, medications, allergies, and medical history.

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What are prescription records?

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Part of a person’s medical records, containing information about medication history, including prescribed medications, dosages, and durations.