Samples of Medical Records

Data Quality
For your selected organization, create three sample Medical Records with the mandatory
fields (1 per page. Use these fields to capture pertinent data as if you were an actual
patient. Using the guidelines from MRI and AHIMA indicate how the information would
be captured (paper or electronically). How would the quality of data you evaluate compare
with your expectations?

Name

How the mandatory fields would compare with my expectations.
In all the three samples, the mandatory fields include patient’s identifiers, reason for
hospital visit, review of the systems, allergies, diagnosis and care plan. The last sample only
captures on patient’s physical examinations, and therefore leaves out on diagnosis and treatment.
The benefit of mandatory fields in the Electronic Medical record is that they act as reminders and
enhances patient’s safety. This implies that the healthcare providers must be extra careful when
filling the field in order to store capture vital information. The mandatory field must be updated
regularly in order to prevent medical errors (Bowman, 2013).
Therefore, it is important for a healthcare provider to take time and decide the
mandatory fields important in their practice, and ensure that the Electronic medical record is
configured in a way that one cannot by pass or disable the fields. My expectation of these
mandatory fields is that they will help improve patient safety, efficiency and quality as well as
help assess potential health disparities. These information will also help maintain patient
information private and enhance coordinated care (Linder, Schnipper, & Middleton, 2012).
References

Linder, J. A., Schnipper, J. L., & Middleton, B. (2012). Method of electronic health record
documentation and quality of primary care. Journal of the American Medical Informatics
Association : JAMIA, 19(6), 1019–1024. http://doi.org/10.1136/amiajnl-2011-000788
Bowman, S. (2013). Impact of Electronic Health Record Systems on Information Integrity:
Quality and Safety Implications. Perspectives in Health Information Management,
10(Fall), 1c.

Systematic data collection form

Name: Myres Jacob
Gender: Female
Age : 31y/o

Height: 6’0”
Weight: 188lbs

Allergies: cold/dust

CC : c/o of nasal congestion and dry cough that started seven days ago
HPI: The patient is 31 y/o Hispanic female reported to the clinic with c/o of nasal congestion and dry cough that
started seven days ago. She reported that she has seasonal allergies and was under Metformin 500mg medicine.
The review of the system was remarkable except for that she had regular but labored respirations, wheezing
sound, productive cough with tan sputum.
Medical history: NONE
Family/social history Father is 79 y/o alive and suffering from prostate cancer. Mother is 76 years old, alive and
asthmatic. Brother is 45 years old, alive and healthy. She is a nursing student schooling at local community college.
She lives alone and is not dating
Medication Metformin
Route oral
frequency twice
Dosage 500mg
Physical exam: Remarkable
ROS The review of the system was remarkable except for that she has regular but labored respirations, wheezing
sound, productive cough with tan sputum
Diagnostic tests
 CBC- pending
 Peak flow
 Allergy test
 Spirometry
Clinical notes
 Asthma: suspected because the patient has had
history of asthma attack, fatigue, SOB and cough

Care plan:

  • Prednisone 40mg PO BID for 3 days,
    Refill ProAirHFA (albuterol sulfate)
    inhaler
  • Promethazine DM syrup Q4-6hr

On call physician medical record

Date: 03/23/17
To: Mr. Raghav, M .

Re: Patient Myre Jacobs Age: 31 years Gender: Female
This patient phoned on 23rd March, 2017 at 10.30 o’clock.
I saw this patient in office Emergency department 23rd March, 2017 at 10.30 o’clock.
Complaint/History/Allergies/Medication
The patient is 31 y/o Hispanic female reported to the clinic with c/o of nasal congestion and dry cough that started seven days ago.
She reported that she has seasonal allergies and was under Metformin 500mg medicine. The review of the system was remarkable
except for that she had regular but labored respirations, wheezing sound, productive cough with tan sputum
Examination:
 CBC- pending
 Peak flow
 Allergy test
 Spirometry
Impression:
 Asthma: suspected because the patient has had history of asthma attack, fatigue, SOB and cough
Action/Advice: Admitted to keep warm and avoid allergens. Patient advised to call in 14 days or if symptoms persists after 24
hrs.
Medication prescribed

  • Prednisone 40mg PO BID for 3 days, Refill ProAirHFA (albuterol sulfate) inhaler
  • Promethazine DM syrup Q4-6hr

Physician initials R. M. . Date 23 rd March, 2017 Pharmacy J.K. L Date 23rd March, 2017

Attachment

Family Name: Jacob’s Given name (s): Myre Date of birth (YYYY-MM-DD): 1986-05-29
For abnormal findings, please give History, diagnosis, treatment plan (include date &medications), lab results,

specialist reports, current status/prognosis
Physical examination Response/Normal Remarks
Height 6’ 0”

X

Normal range

Weight 188lbs

X

Normal range

BMI 25.54

X

Normal range

Bp 120/75

X

Normal range

RR 15 laboured

X

Abnormal

Ear/Nose/Throat/Mouth

X

No hearing difficulties, no nose bleeds, denies dental
problems, nasal congestion associated with yellowish-mucous
discharge

Eyes (include fundoscopy)

X

No eyesight changes, denies itchy eyes

Breast examination

X

Deferred

Cardiovascular system

X

Denies palpitation or angina, no murmurs, gallops or rubs

Respiratory system

X

Regular respirations (labored) wheezing sound, productive
cough with tan sputum

Nervous system (sequeale
of cerebral palsy, stroke or
other neurological
disabilities

X

Denies neurological disorders

Cognitive state

X

No cognitive impairements

Gastrointestinal system

X

Normal bowel movements, no changes in appetite

muscoskeletal

X

No injuries or backache issues, ROM in all quadrants

Endocrine system

X

Denies any health complication

Other physical or mental
health condition

None NKDA

Looking for Discount?

You'll get a high-quality service, that's for sure.

To welcome you, we give you a 20% discount on your All orders! use code - NWS20

Discount applies to orders from $30
All Rights Reserved, Nursingwritingservice.com
Disclaimer: You will use the product (paper) for legal purposes only and you are not authorized to plagiarize. In addition, neither our website nor any of its affiliates and/or partners shall be liable for any unethical, inappropriate, illegal, or otherwise wrongful use of the Products and/or other written material received from the Website. This includes plagiarism, lawsuits, poor grading, expulsion, academic probation, loss of scholarships / awards / grants/ prizes / titles / positions, failure, suspension, or any other disciplinary or legal actions. Purchasers of Products from the Website are solely responsible for any and all disciplinary actions arising from the improper, unethical, and/or illegal use of such Products.