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Information BulletinNonAdmitted Patient Data Collection: Classification and Code Standards from 1 July
2017
Summary The purpose of this information bulletin is to inform NSW Health service providers
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How to fill out health care records
How to fill out health care records
01
Start by gathering all the necessary information about the patient, including their personal details such as name, date of birth, and contact information.
02
Record the patient's medical history, including any pre-existing conditions, past surgeries, and ongoing medications.
03
Document the patient's vital signs, such as blood pressure, heart rate, and temperature.
04
Record any allergies or adverse reactions to medications.
05
Include information about any ongoing health issues or symptoms the patient is experiencing.
06
Document any diagnoses made by healthcare professionals and the corresponding treatment plans.
07
Record any laboratory test results and imaging studies.
08
Include information about any hospitalizations or emergency room visits.
09
Document any follow-up appointments or referrals to other specialists.
10
Ensure that all entries are legible, clear, and concise, using standard medical terminology.
11
Update the health care records regularly as new information becomes available.
Who needs health care records?
01
Health care records are needed by various individuals and organizations, including:
02
- Patients: Health care records provide a complete and accurate record of their medical history and treatments.
03
- Healthcare professionals: Medical practitioners rely on health care records to make informed decisions and provide appropriate care.
04
- Insurance companies: Health care records help insurance companies assess the medical necessity of treatments and process claims.
05
- Researchers: Health care records serve as valuable sources of data for medical research and clinical studies.
06
- Regulatory bodies: Health care records aid regulatory bodies in monitoring medical practices and ensuring compliance with standards.
07
- Legal entities: Health care records can be used as evidence in legal proceedings related to medical malpractice or personal injury.
08
- Government agencies: Health care records are required for public health monitoring, disease surveillance, and policy-making.
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What is health care records?
Health care records are documentation of a patient's medical history, diagnosis, treatments, and outcomes.
Who is required to file health care records?
Health care providers and facilities are required to maintain and file health care records for their patients.
How to fill out health care records?
Health care records are filled out by health care professionals during patient visits, documenting all relevant information regarding the patient's health.
What is the purpose of health care records?
The purpose of health care records is to provide a comprehensive and accurate record of a patient's medical history, treatment, and progress for future reference and continuity of care.
What information must be reported on health care records?
Health care records should include patient demographics, medical history, treatment plans, medications prescribed, test results, and any other relevant medical information.
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