A medical progress note is a document that is filled by a medical provider regarding the patient's condition after receiving some medical treatment. This document shows whether, during the hospitalization, the patient has progressed with their illness or not. It was commonly written by the nurse who directly takes care of the patient all the time and then gives the report of the patient's condition to the doctor. The medical records are used to compare current patient conditions, tools to discuss health issues finding, gain other perspectives from the medical care teams over the disease, and review the cases in detail.
The progress notes have some criteria that the medical team requires to apply while making the create it. These documents should be easy to read, understandable, concise, accurate, and in a complete version. Besides, this note should be flexible in case there is additional information that needs to be input into the records. The medical progress notes are usually written in many types which are adapted to the health care situation. One of the forms is using SOAP note which acronym for subjective, objective, assessment, and plan.
The subjective from the progress note means the purpose of the patient's visit to the hospital, the objective is the information that medical providers gain from the patient that they already observe, assessment means the medical diagnosis, and the plan is the procedure of health care that the patient will experience during the hospitality. As a result, the facts of medical progress notes might be something that everyone is curious to know. So, when you are in a hospitality situation, do not ask anymore why the nurse always checking you every time. You are allowed to share any kinds of illness and uncomfortable that you feel on your body during the treatment. The nurse will record your condition and report it to the doctor.
A medical record serves the information about your health condition. The National Health Service provides separate records of your medical condition such as surgery, hospital, dentist, optician, and so on. If you want to get your medical records, make sure you have already experienced the treatment with the medical provider before. In case you needed, the medical record includes the information of any condition such as allergies and the medication name you’ve been taking.
Here are the ways you can take to get your medical records. Use your national health service account by logging in from the website or the app. If you haven’t created the account, you may register first. However, you still need to ask your general practitioner to have full access to your medical record. You can also directly ask for your record from the general practitioner that maintain your health care previously. If you are in the improper condition of accessing your health records, choose one of the trusted people to access this kind of confidential record for you. To prevention on your data gets leaked, the family is the most reliable note as a guardian.
Having documentation regarding your body's thorough condition is quite important. To track the progress of the patient, the providers use the patient history record as a tool. The purpose of having a medical record is to serve complete information and an accurate description of a patient’s condition. This document includes your health condition history, the diagnoses, the care and the treatment you got, and the result after treatment. A well-arranged record will serve relevant information on patients’ health which is used as a tool to serve the effective communication among the teams.
From the medical providers’ point of view, it can be used as the documentation that may help them to prevent a lawsuit. Due to the cases of malpractice that possibly happen, the patient can assert regarding the impropriate treatment that they have from the medical providers. Using the medical record as proof, the doctor will be able to defend their medical team. That’s why the medical record should be written in a formal form. The documents also have some important elements as the requirements.
The record should be legible to make anyone who read it will understand what the information includes. Keep the documents’ having the time that takes place accompanied by the medical team’s signature. The record needs to be accurate based on the current patient’s condition. It will be easier to understand if the documents are sequential by date and logical in the process. The document should be written precisely. This document should be created in a specific way, for example, the medication that the health care provider gives to the patient should be written in detail and actual measurements.
From the statements, those records are both very useful to the patient and health care providers. Patients can track and know their condition and the treatment they give during the hospitality. The doctor can use the medical record as a defense against cases that might happen and use the document as an effective communication tool among teams. This legal document is way too important for the parties. That’s why only certain people can access someone’s medical records.