Medical Forms

Medical forms, in other words, known as medical records, are very pivotal in the provision of care. Indeed, medical forms help in documenting information about the client’s identity, the past medical history, the present medical status, and the management of the particular client. In the hospital setting, a client passes through various stages like the administration, the financial department, the laboratory, the social work and counselling department and the clinical area, among others. In these different areas, the client is attended by different people. To deal with the challenge of maintaining consistency of care, the medical forms bridge this gap. As such, medical records can be categorized as administrative and demographic forms, financial forms, clinical information records and clinical observation forms, among others. Still, these forms can be looked at in the precincts of admission forms, care provision forms and discharge forms (Roach, 2006). Apart from documenting patient information and care, medical forms play other vital roles, for example, dealing with legal issues. The current essay provides descriptions and distinctions of various medical forms in regard to a patient undergoing a minor surgery.

Medical forms accompany the process of care from the beginning to the end. When a client visits a hospital, their basic information and demographic data are recorded in administrative patient forms for identification purposes. It is then they are given numbers, which may differ according to organizational policies (Roach, 2006). The information is filed by the administrative team. In most institutions, the patient proceeds to pay for the consultation service, upon which they are offered a receipt of payment, and the data is entered in the financial forms. The financial data entry process is simultaneous with the delivery of care until the client leaves the hospital, upon which they are given a summary of their financial undertakings with the hospital.

After paying for consultations, the process of care is accompanied by other forms, including the patient history form, which is used to record the patients’ past medical history, the presenting condition, the family social history and any other relevant information to aid diagnosis. Henceforth, the patient proceeds to have their observations taken, which includes the pulse rate and blood pressure, among others (Roach, 2006). These are recorded in the patient’s observation form, which is attached to the other previous forms. When the patient sees a doctor, the doctor writes their findings in a physician consultation form. At this stage, the doctor may order investigations, which now brings into play the laboratory request forms, and the laboratory reports. In the case of imaging, unique imaging records such as X-rays are used. The physician may also need to look at the patient’s past records in order to plan care well. This brings another clinical record called the treatment plan form.

In our case, the client will need to go to the theatre for a minor surgery. The patient will need to fill a consent form. The doctors will need to order various investigations before the client goes for surgery. The client may be admitted for surgery, upon which the nurse fills the patient admission form. In case the client is allergic to some substance, the nurse will need to fill a special form to that effect. The nurse also fills a pre-operative list as he/she prepares the client for the surgery (Roach, 2006)

In sum, medical records are a very detrimental part of health care delivery. The forms accompany the process of care at all the stages. They are handled by different people, and they fill the gap, which would lead to inconsistencies in the delivery of care.