6 different types of medical documents.

Posted: July 12th, 2022

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Topic given to discuss:Besides Letters, Memorandums, and Emails, what other types of documents may be created in a Medical office setting? What would be the purpose and who would be the primary audience? Provide one reference to support your discussion.
Two persons give their views, Discuss your views on each parts below separately. Do not link or compare part 1 with part 2. Give thorough views or each agree to disagree. APA 7th edition style Please provide reference with url/doi link
PART 1
I work here at the Baylor Scott and White Health, and one of my favorite documents for patients visit is the “Patient After Visit Summary”. The audience is directly to the patient. The information included is everything that was added and changed when the patient started their appointment. From additional diagnosis, discontinued or added medications, vitals signs, will also show the chief complaint, etc. This summary will also include their next appointment, numbers for testing sites that will be calling them to schedule appointments for any testing or procedures.
A patient registration form helps gather the patients personal information online. Usually it is filled whenever the patient is visiting the clinic and it is used for record keeping. It is also called a patient admission form. It will include the patients personal information; DOB, phone number, martial status, insurance information, emergency contact and also your employee information. The most important information that is needed is the problem list, allergies, and if you are pregnant. These forms the clerical will inform you to come 30 minutes prior to complete them beforehand.
Every patient visit consists of a diagnosis and treatment plan. The provider is the main individual that notates this documentation and is posted on the patients visit notes, and chart. The audience is directly to the patient, the provider to look back at when the patient ask questions in the long run. Due to the amount of patients the provider sees, this documentation is very useful. It is also directly to our clerical which is used for scheduling the patient at a certain clinic, any testing that is needed to be scheduled. The provider will always add a notation of somewhat like “See patient back for a 1yr or 6 month follow up”. This is where the Clerical team comes in and schedule the appt, labs, procedure, or testing. As a CMA i use the diagnosis and treatment plan when filling prior authorization, informing patient on the treatment plan that the Provider discussed with them during their last visit.
The provider have to fully understand why the patient is there, needs, symptoms in order to match for a diagnosis (Bray, 2021). Then a treatment plan is included to help resolve the patients condition.
References
Bray, B. (2021, September 22). Assessment, diagnosis and treatment planning: A map for the journey ahead. A Publication of the American Counseling Association. https://ct.counseling.org/2021/09/assessment-diagnosis-and-treatment-planning-a-map-for-the-journey-
PART 2
Types of Documents in the Medical Field
In the medical field, there are various different types of documents that are created in the medical office setting. There are documents such as Patient Registration Forms, Medical History, Physical Examination Forms, Consent Forms, Laboratory Results, Diagnosis and Treatment Plans, Operation Reports, Follow Up Visits, Telephone Calls, and Hospital Discharge Summaries. After conducting my research there are more documents but in this discussion, I chose to go with all the following that I have listed. The majority of these documents purposes are mainly for the patients. Every single one of these forms is what creates a Medical Record in the Hospital or even in a clinic for a patient.
I recently went to my doctor’s appointment at a new doctor’s office after recently moving to Macon, GA and the first thing the nurse at the front desk made me do was fill out a Patient’s Registration Form. The purpose of this form is to give the doctor relevant information such as your name, address, social security and etc. about the patient to put into the medical system that the doctor’s office has. This form to me personally is similar to a background check. After giving the nurse my form she gained complete access to my Medical History. The purpose of a patient’s medical history is to see if the patient suffers from an illness, to see if they have had any surgeries (past and recent), what kind of allergies they might have, family member’s medical history, and current medications that the patient is actively using. All of this information can give the doctor all the resources to treat the patient.
Next, after filling out my registration form and gaining access to my medical history there are other aspects that show up on my medical history. Certain aspects such as Laboratory results, lab results such as blood work and samples and etc. A diagnosis and treatment plan is a plan that the doctor creates for the patient to follow along to treat whatever diagnosis the doctor has provided for them. Consent forms, are forms that the nurses usually give you to fill out whenever you are about to get surgery or take an MRI so that the hospital staff is protected if there are any fatalities during the procedure. Another aspect such as Operation Reports, there are usually notes that medical assistants and physicians report down for procedures and surgeries. And lastly, Discharge summaries and Follow up visits.
Overall, medical documentation enables medical professionals to gather and record all relevant information on patient’s current and previous health conditions and treatments that they have received from any medical setting. Hopefully, everyone reading my response has similar information and I’m looking forward to reading your opinions on everything that I have stated in my discussion.
References
Becker Media. (2022, June 15). Guide to Medical Office Records Management Procedure. Hunter Business School. Retrieved July 10, 2022, from https://hunterbusinessschool.edu/guide-to-medical-office-administration-records-management/
L. (2022, May 30). 6 different types of medical documents. Okomeds. Retrieved July 10, 2022, from https://www.okomeds.com/6-different-types-of-medical-documents/

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