The electronic medical record includes
progress notes
The electronic medical record (EMR) is a digital record of a patient’s medical history, which encompasses a wide range of information about the patient. This may include:
1. Personal information: The patient’s name, address, phone number, date of birth, gender, etc.
2. Medical history: The patient’s past medical conditions, surgeries, allergies, medications, diagnostic tests, and immunization history.
3. Clinical notes: The physician’s notes, nursing notes, and allied health professionals’ notes relating to the patient’s care, including progress notes, diagnostic impressions, treatment plans, and discharge summaries.
4. Vital signs: The patient’s vital signs, including blood pressure, heart rate, temperature, oxygen saturation, respiratory rate, and weight.
5. Imaging and diagnostic reports: The patient’s X-rays, CT scans, MRIs, and other diagnostic reports.
6. Laboratory results: The patient’s laboratory test results, including blood tests, urine tests, and other tests.
7. Patient demographics: Information about the patient’s race, ethnicity, occupation, and other demographic data.
8. Billing and insurance information: Information about the patient’s insurance plans and billing history.
9. Consent forms: Electronic signatures and consent forms for treatments, surgeries, and other medical procedures.
In summary, the EMR stores comprehensive information about the patient’s medical history, providing healthcare professionals with detailed information to inform their medical decision-making process.
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