The field of health and medicine has always been meant to take care of the humankind. Doctors and other nursing and paramedical staff all are always interested in saving human lives and then making it better and worth living by providing them better health and reducing the morbidity and mortality.
Importance of medical record
When a patient feels the need for a doctor’s consultation, they usually come to the doctor’s clinic and explain their problems. In a properly organized and well-established hospital settlement, there is always a department of medical records. The purpose of the medical records departments is to keep a record of each and every activity regarding patient and patient care.
This is the reason why a doctor’s visit record is also maintained. Like all other records, this medical record is also used for future correspondence. It is also used for a retrospective tracing of any undesirable event.
Description of a doctor’s visit record
- On each visit, a form is filled in the name of doctor’s visit record which proves to be useful both for the hospital and the patients as well.
- A doctor’s visit record sheet always begins with the introduction of the patient. In the introductory section of the form, patient’s name, age, sex, date of birth and contact number along with address is noted down. The reason is simple, identity and basic information and clues.
- If the patient is a female, we do ask her about her marital status. We are also interested in knowing whether she is pregnant at present or not. If she is pregnant, the whole agenda and management plan change for such patient altogether. If the female patient is non-pregnant but a nursing mother, we are again concerned with the careful management and prescription to save the breastfeeding baby.
- After knowing the initial points about the patient, a doctor asks the main concerns of the patient for which he had to come to the clinic. We also called this as the presenting complaints. Presenting complaints of the patient as always inquired in detail and written in an elaborate fashion.
- If necessary or if this is the first visit of the patient, past medical and surgical history can also be written along with any positive history of allergies or past medications.
- Some details of the appointment with the doctor are also mentioned in the form. The date and time of the appointment, doctor’s details and reason for appointments are also mentioned in the doctor’s visit record.
- Doctor’s details are important especially in hospital management because we always want to make sure that the patient consulted the right doctor. This information is also used for future follow up and discussions purposes.
- A doctor always mentions his diagnosis in the form to confirm that the patient was consulted and evaluated according to the best of interests of the patient. The doctor also rights down the advice or management plan in this section which tells what is cooking in his mind regarding the patient and how the patient was counseled.