Part of job description for a medical assistant constitutes a sequential record of care and utmost treatment usually referred to as medical records. Besides being important for a medical assistants care, they are also important for clinical and legal purposes. This paper thus aims to highlight the types of medical forms commonly dealt with. Also, it sheds light on the information contained in every form and the systems are available for filing.
As opposed to health records which are broad, medical forms are narrow and contain details only pertinent to mental and physical conditions used and proposed by providers. Such forms include the following.
This form contains the vital statistics, e.g. sex, age, address, name, marital status, place of birth, and Social Security Number. It also contains facts relative information which states the attending physician, admitting diagnoses, date and time of admission and anticipated procedures (International Foundation of Employee Benefit Plans, Inc., 2003).
Consent to treatment statement form
This is executed by the patient. It contains a statement that puts patients under control of hospital for either nursing care or general care and under control of attending physicians care. It gives information to insurance companies and employers. The form also gives a patient expectation and right as regards security of his/her valuables. It also contains information that ensures that patient responsibly pays for hospital bills (International Foundation of Employee Benefit Plans, Inc., 2003).
Medical history
This form shows the outline of the patients’ medical history. It contains items like chief complaints, present illness, family history, past medical history, personal habits and specific health questions.
Progress report form
Also called the Physician’s Notes, it relates to patient’s illnesses, status of discharge and treatment.
Maternity records forms
These records included in the maternity unit and include the Specialized Physical Examination, delivery and labour room record, postpartum record and infant data.
Outpatient general record
This is a record for the outpatient visits. It may contain information that relates to vital statistics, history of physical examination, physician and nurses notes and reports of laboratory (International Foundation of Employee Benefit Plans, Inc., 2003).
The systems available for filing on the other hand include record oriented file systems, distributed file systems, database file systems, transactional file systems, network file systems, flat file systems e.t.c. database based filing is the best because files can be identified with their characteristics, e.g type, topic e.t.c.
Reference
eHow Contributor. (2012). What Types of Medical Record Forms Are There? Retrieved 27 August, 2012 from http://www.ehow.com/list_5927930_types-medical-record-forms-there_.html
International Foundation of Employee Benefit Plans, Inc. (2003). Medical Records Guide. Retrieved 27 August, 2012 from http://www.ifebp.org/pdf/harker/Medical_Records_Guide.pdf
Southern California Computer Forms & Labels. (2012). Healthcare forms & products. Retrieved 27 August, 2012 from http://www.inkoneverything.com/medicalformsalltypes.html
