Medical charts are important tools used in documenting and recording a patient’s health condition. Organizing a chart is not the same in all hospital setting. Different hospitals use different kinds of medical charts and arrange them in their own systematic way. However they are arranged, they are still used to document and record a patient’s health and wellness.
There are different types of charts being used in a medical institution and to name all of them would take some time. To be able to check on some of them, why not take a look at these free chart sample that we have made available just for you.
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What Is the Job of a Medical Reviewer?
A medical reviewer is an auditor in the medical field or a medical auditor. They audit or review medical records to make sure that a certain institution is following the standard procedure in documenting charts and other patient records. They make sure that all the records that are documented are accurate and complete. Any missing information may lead to a hospitals losing its accreditation. If there is excessive documentation errors, it may result to closure of the hospital. Medical reviewers work in physician hospitals or independent auditing firms, to name a few. You might find free charts and blood pressure charts useful.
What Does a Medical Chart Analyst Do?
A medical chart analyst differs from a medical reviewer because their duties and responsibilities are to organize and maintain the the health care records of the patient. Unlike a medical reviewer whose job is mostly about fault finding, a medical analysts ensure that all information entered to their system are all accurate and complete. They can also make reports based on the data that they have analyzed. Because they are analysts, they also perform duties like interpreting the bill and provide a report about the hospital’s financial activities. Also take a look at our printable time chart.
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What Is on a Medical Chart?
A medical chart is document where a patient’s medical information is recorded. This chart should be taken and handled seriously as it will serve as a proof and basis for a patent’s care. It is also a legal document that can be used to prove someone’s innocence or to prove that they are guilty. Writing false and faulty information in the chart is also dangerous to both patient and health-care provider. That is why the information included in a medical chart is crucial. Below is a list of what is on a medical chart. You might want to check out our Boy Scout medical form and free time charts.
- A patient’s general information and baseline data
- Their chief complaint
- Past and present medial history
- Family hereditary diseases or their family history
- Surgical history
- Their vital signs like temperature, blood pressure, heart rate, and respiratory rate
- Medications and medical allergies
- Obstetric history
- Immunization record
- A patient’s progress notes
- Their laboratory test results like MRIs, CAT scans, X-ray, blood testing, CBC, etc.
- The patient’s assessment, like physical, mental, or neurological
- The doctor’s notes, orders, and medicine prescriptions
- The patient’s habits, if they smoke, exercise, drink alcoholic beverages
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