Health records for inpatients should contain what information?
1)Patient identification data
2)Number of patient visitors during the stay
3)Reports of any diagnostic or therapeutic studies
4)Physical examination data
5)Number of times the nurse call light is activated for nursing care
6)All informed consent documents
7)Medical history,including the chief complaint

Question

Quizplus · Accepted Answer

Regardless of the method used to record health information,the content of each health record depends on which health care facility department is treating the patient and recording the information.Standards for inpatient records require that the records include the following information:
•Patient identification data
•Medical history of the patient provided by the patient,including chief complaint,history of present illness or injury,relevant family and social histories,and inventory by body system
•Report of relevant physical examination findings
•Diagnostic and therapeutic orders
•Clinical observations,including results of therapy
•Reports of diagnostic and therapeutic procedures and tests,as well as their results
•Evidence of appropriate informed consent (when consent is not obtainable,the reason should be entered in the record)
•Conclusions at termination of hospitalization or evaluation of treatment,including any pertinent instructions for follow-up care

Health Records for Inpatients Should Contain What Information