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Site Development Manual: Chapter 13
Exhibit 13-1: MEDICAL RECORDS SYSTEM
Medical Information that Should be Contained in the Medical Record
| Medical history |
Family history including diseases, health status, ages, causes of death of family members; personal history including prior diseases, operations, signs, symptoms, complaints, allergies, previous treatments; current therapies including drugs, transfusions, dental care, vision care, previous diagnostic and therapeutic radiology services, immunizations, and vaccinations. |
| Current health care |
Systems review; diagnoses; current signs and symptoms; current complaints; habits; use of drugs, tobacco, and other substances; personal behavior, including work environment and exposures, recreation; pregnancy and menstrual background and current status; emotional and mental health problems and background. |
| Results of services provided |
Laboratory, radiology, other ancillary services results, and consultant and referral letters and notes. |
| Progress notes |
Physician and other services provided; notes and comments on care; recordings of patient progress and instructions, diagnoses, tests and procedures ordered; other observations and notes. |
| Other information |
Hospital discharge summaries, surgical reports; ancillary test requisitions; record release and other legal and administrative records material; problem list, medication list, summary therapy list, treatment plans, discharge plans; social worker and other professional notes, letters, evaluations, and assessments. |
Ross, Austin, Williams, Stephen J., and Schafer, Eldon L., Ambulatory Care Management. p. 205.
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