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Medical Record The medical record shall include, at a minimum, the following items (if applicable): Address Acquired harms Do you feel you have been harmed? How have you been harmed? Has the patient been harmed? Have you been harmed? What are the various acquired harms? Here are further guidelines. Activities of everyday living Anthropometric measurements Annual health assessment Annual Physical Examinations Assets Birth History Birth Defects Does the patient have any birth defects? Do you have any birth defects? What are some of the various birth defects? Here are further guidelines. Complaint Complaint Problem Death Investigation Education Emotions Emergency Medical emergency Detention Emergencies as per medical specialties On-the-spot emergency medical diagnosis and treatment. On the way to the hospital treatment. Emergency room treatment. In-hospital treatment. Critical care treatment. Outpatient follow-up treatment. Online treatment. Follow-up medical consultation Family History Friends Food Functional Assessment Health Calculators Habits Hospitalization records Harmful females Identity Card Internet health care resource for the resident. Language Laboratory Tests Last updated Life stressors screening Medical emergency Mental status examination Medical record correction Medical doctor to medical doctor communication about patient Medication Medical Doctor Medical emergency resource for the resident. Mobility Functional Assessment New Patient Consultation New Patient Outpatient medical services record Patient Profile Profile Past medical history Primary health care physician for the resident. Physical fitness questions Patient to medical doctor communication Patient been referred to you by others Profile People Problem/Complaint Patient Education Patient been referred by you to others Patient to medical doctor communication Past History Patient Education Profile of patient Profile of patient Patient Satisfaction Health Care Opinion Survey Health Care Well-Being Personality questions Physical examination Relatives Relationships Religious Preference Relationship Counseling Screening Skills Surgery Surgical Documentation Survival Needs School-based screening Hearing and vision deficiencies Dental problems Posture issues Sleep History Questions Do you have any difficulty falling asleep? Are you having difficulty sleeping throughout the night? Here are further guidelines. Travel history Talking with Your Doctor Vitals Consciousness is extremely essential in reaching a correct diagnosis and treatment. Consciousness, pulse, blood pressure, respiratory rate, temperature. Female Medical History Patient Information What is your name? ________________________ First Name:______________ Last Name:______________ What is your real, birth name? ______________________________ Where and when were you born? ______________________________ How old are you? ______________________________ What is your Email address? ______________________________ What is your mailing address? ______________________________ What has been your mailing address from the time of your birth until now? ______________________________ What language do you speak? ______________________________ What is your height? ______________________________ What is your weight? ______________________________ What is the color of your skin? ______________________________ What is the color of your hair? ______________________________ Lifestyle Information What is your normal day like? ______________________________ Do you smoke? ______________________________ Do you use alcohol? ______________________________ Do you abuse any drugs? ______________________________ Contraceptive history Diet Emergency What medical history and physical examination is required in a pregnancy emergency? Here are further guidelines. What are human pregnancy medical emergencies? How should you do a quick assessment, diagnosis, and treatment of a person reported as a human pregnancy medical emergency? Family History Human Pregnancy What should you know about human pregnancy? Here are further guidelines. Menstrual history Obstetric history Personality questions Previous Pregnancies Planning for pregnancy (Parenting Advice) Problem/Complaint Do you have any problem, complaint, or issues as of today? History of Present Pregnancy History of Present Illness Past medical history Provisional Diagnosis Pets Do you have any domestic pets? Domestic pets, Dogs, Cats, Birds, Farm animals. Sexual Health (Health & Sex.) New Patient Consultation Female Medical History Obstetrics & Gynecology History Children Menstruation Ethics Family-Centered Maternity Care-Pregnancy Prenatal care Physician Details Pregnancy (Initial profile) 1st Trimester 2nd Trimester 3rd Trimester Children Annual health assessment of children. Acquired harms Birth History Birth Defects Pediatrics. Hospital Patient Hospital Patient Hospital Hospital Medical Record Cardiology Psychiatry Gastroenterology Disability Specialist Geriatrics Medical record Medical history Medical law Patient Profile Aisha (mummy) Who should maintain electronic health records? The state department of health. A medical doctor and his or her team. How often should electronic health records be updated? Electronic health record should be updated as soon as new findings are available. What is the medical history of a patient? The medical history of a patient is a longitudinal record of what has happened to the patient since birth. What is the difference between medical history, medical record, electronic health record, and emergency medical record? If you have a new patient, you have to get his or her medical history since birth. This is medical history. Once this medical history is maintained in any format (paper, electronic), this becomes a medical record. A medical record preserved via the Internet is an electronic health record. All facts gathered during a medical emergency become an emergency medical record. Did you know that 90% of doctor visits are for stress related symptoms? How many human medical conditions are there? There are more than 7,000 human medical conditions. Why should you call them medical conditions instead of diseases? Diseases usually indicate an underlying pathology. Not all medical conditions have an underlying pathology. How many medical conditions are caused by stress? More than 100 medical conditions are the result of stress. These are the most common medical conditions. Why is there a need to elaborate on life stressors? Life stressors are most common cause of various common medical conditions. Medical Doctor Is this complaint about your health or someone else s? What best describes the complaint about your health? New Patient Consultation http://www.qureshiuniversity.com/medicalhistory.html Medical emergency http://www.qureshiuniversity.com/medicalemergency.html What are the sources of medical history? Patient. Family. Patient not responding to medical history questions. Community member. Police officer. Referral from medical doctor. Other. What are various emergency guidelines for the public? http://www.qureshiuniversity.com/emergencyguidelinesforthepublic.html Who has the medical record of the patient? What should a medical record of a patient look like? Who should update the medical records? How is a medical record maintained? Electronic medical record. Medical records in paper format. Emergency medical record. What should a medical record contain? What should an emergency medical record contain? What are the scenarios in which medical records can be obtained? Routine requests for medical records. Legal proceedings or in response to a request to release patient medical records. Court. Updating the medical records. Workers in Health Care What are various workers in health care? http://www.qureshiuniversity.com/workersinhumanhealthcare.html How should you communicate with your medical doctor? Who is your primary care physician, medical emergency resource, Internet health care resource? This should be communicated to the residents in the state. Internet health care resource for the resident. Primary health care physician for the resident. Medical emergency resource for the resident. What should be the priority of the health care system? What are various methods to list a medical record? How should every state department of health maintain medical records of all residents? In alphabetical order. Based on specific pattern or institution. A medical record in alphabetical order is preferable.