Health records are the collection of different documentations made from the time a patient is admitted to the hospital up to the time of release of the patient. Health records contain the important data of the transactions, medications, and patient information which are essential for other future reference once the patient goes out of the hospital (MacLennan, n.d). As such, different forms are made and every one of them has different purposes and is highly recognized by other hospital personnel and even other transactions outside hospital.
Upon admittance to the hospital, the patient (or the relatives if patient is unavailable) an administrative information data will be required to relation with registration especially during the first time of admittance in the hospital. This includes personal information and other necessary data which will be put into a designated registration storage wherein the data will be stored for future use. This registration storage is now computer-based and is connected to the ‘Master Patient Index’ (Fahrenholz & Russo, 2013). The administrative information data can be used once again in the case the patient is readmitted to the hospital. Providing administrative information will save the time of patients from doing the registration once they come back to the hospital since the data are stored securely in the database and can be re-accessed again (Fahrenholz & Russo, 2013).
In relation with the administrative information, demographic data is also needed by the patients to fill up because it will be used as reference for other transactions and information such as statistical and research studies (Fahrenholz & Russo, 2013). More importantly, demographic data serves as the personal identification of the patient, and this will be one of the bases of the hospital in case problems related to identity loss occur. In a demographic data, basic information such as name, address, contact details, gender, birth details, civil status, and identification numbers are included (Fahrenholz & Russo, 2013).
Hospital bills sometimes depend on the social status of patients. In relation to this, a financial data must be completed so that the financial status of the patient can be addressed immediately to either the administration or to other financial assistance agencies in order to make necessary amendments for the patient (Fahrenholz & Russo, 2013). By filling up the information sheet and providing the necessary documents, the patient may be granted the appropriate discount and will save the expenses for hospital bills. In a financial data, the patient’s name, the third party’s name and other details (should be directly related to the patient), insurance information, and employer’s information (in case the patient is working and granted benefits by the employer) can be seen (Fahrenholz & Russo, 2013).
As the treatment process goes on, necessary documentations are made in order to record information such as the needed medical treatment and the reasons on taking that treatment process (Fahrenholz & Russo, 2013). As such, a clinical data must be completed by the patient to proceed for the treatment. In a clinical data, information such as clinical history, patient’s current condition, and the treatment needed can be seen. For example, if the patient is required to undergo a minor surgical procedure, the surgery will proceed if there will be no conflicts with medical history of the patient in relation with the risks that might be incurred during the operation. Clinical data will also serve as proof that the patient undergoes the treatment process, which will be important for faster recovery of the patients since doctors can only provide prescriptions of other medicines once treatment has been done.
Also, during the treatment, observations made will be given to the patient in order to make them aware of the progress of their condition before, during, and after the treatment process. Clinical observations are written in a certain official sheet and the doctor who initiated and administered the treatment will be the one responsible to provide the necessary information to the patients (Fahrenholz & Russo, 2013).
Patient forms can be quite tiresome as there are several documentations needed to be filled up before the treatment proceeds. However, these documents will be used for own future references and the data associated within these forms will be helpful enough to assist the patients in tracking their health once they are discharged from the hospital. It is advisable to fill up the information honestly and correctly so that the ideal results can be nearly obtained and the satisfaction of the patients will be guaranteed.
Fahrenholz, C. G., & Russo, R. (2013). Documentation for Health records. Chicago, Illinois: AHIMA.
MacLennan, R. (n.d.). Items of patient information which may be collected by registries. Brisbane, Australia: Queensland Institute of Medical Research.