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Efficient Medical Record Framework for Patient Care

Explore an innovative data structure for comprehensive patient records, including medical history, vital signs, and more. Enhance healthcare quality and efficiency with the latest elements. October 13, 2011.

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Efficient Medical Record Framework for Patient Care

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  1. S&I Framework B Data Elements(Harm. Team) October 13, 2011

  2. Admitting and Discharging Diagnoses

  3. Equipment

  4. Family History

  5. History of Present Illness

  6. Immunization History

  7. Invasive and Non-Invasive Procedures

  8. Medical History

  9. Medication History

  10. Medication History (contd.)

  11. Medication History (contd. 2)

  12. Operative Summary

  13. Patient Instructions

  14. Pending Tests and Procedure

  15. Physical Exam

  16. Reason for Consult Request

  17. Review of Systems

  18. Results

  19. Social History

  20. Surgical/Procedural History

  21. Vital Signs

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