The Basics of Medical Record Abstraction

Medical Record Abstraction

Medical record abstraction is a vital part of the healthcare data conversion process. It involves collecting and entering crucial medical information into a new electronic health record system.

Abstracting a patient’s record is challenging, time-consuming and requires attention to detail. Therefore, it’s crucial to choose a vendor with experienced staff.

Patient’s Medical History

The patient’s medical history is a vital element of every patient encounter. It provides critical patient health information and allows doctors to make informed treatment and preventive care decisions.

A patient’s personal and family medical history can help doctors understand how likely a patient is to develop a particular disease or illness. This information can help save lives by identifying high-risk factors that might lead to future symptoms or diseases.

History of Present Illness

The history of the present illness (HPI) is the first part of every medical record and tells the patient’s story. Without this information, physicians can’t truly understand their patients or provide them with the necessary care.

The HPI is the foundation for developing differential diagnoses, determining a diagnosis, and guiding treatment. It involves obtaining subjective data from the patient about the onset, location, duration, character, alleviating factors, radiation, temporal patterns, and symptoms.

Current Physical Condition

The current physical condition is vital to any patient’s medical record. It contains information on the onset, complaints, severity, quality and chronology of the patient’s condition.

The current medical record can also contain other information, including premalignant conditions, comorbid conditions, medications and diagnostic impressions. A medical record abstraction even includes an abstract graphical representation of the data in graphs, diagrams and charts.

Past Medical History

Taking medical histories is a core skill of all clinicians. It lets them understand a patient’s health and helps your doctor diagnose and treat you better.

Your medical history includes your overall health status, prior illnesses and treatments, hospitalizations and other medical problems. It also consists of any procedures, X-rays, scans or further testing.

Patients with a clear medical history will be more likely to respond to questions about their current problems. It may save their life if they have a traumatic accident or illness or can’t remember their health details.

Social History

The social history of a population is the record of its people’s lives and social relations. It is a sub-culture of historical inquiry that emerged in the mid-twentieth century as a reaction against the dominant fields of political, diplomatic and ecclesiastical history, which, in their focus on elites, failed to address the lives of the majority of the human race.

Like all other manifestations of culture in the 1960s, the new social history was shaped by conflicts and issues of the time. They were embodied in the movement of Afro-Americans, students and women and the growing reorientation of the social sciences towards society and the humanities.

Family History

Family health history records medical information about a person and their close relatives. Healthcare professionals use it to identify individuals at higher risk for certain conditions and recommend prevention programs.

A family history can show if you are prone to specific illnesses, like heart disease, cancer, or diabetes. But it doesn’t mean you will develop those conditions.

It also helps doctors and other medical staff understand how your genes interact with how you live and the environments you experience. It can help them prevent or treat a variety of diseases.

Preventive Care

Preventive care is the stuff you do before something goes wrong. It can help you avoid illness or disease, live longer, and save money by catching problems early.

Many preventive services are accessible to people with health insurance plans. These services include screenings, tests, and vaccines.

Your doctor may recommend different screenings and immunizations based on your needs or risk factors. You can follow the guidelines below to prepare for your visit and talk with your doctor about what suits you and your family.

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The Basics of Medical Record Abstraction

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