9.2 : 健康记录的目的I

The purposes of medical records are described in this lesson.

Health records are communication tools among the health team members used to promote continuity of care for the patient among the different departments during their hospital stay.

Health records also help in reviewing diagnostic and therapeutic orders. For example, healthcare providers can verify any diagnostic tests performed on the patient since admission and review pertinent care orders.

Records help in planning care. Healthcare staff working with the patient can access the baseline and ongoing data and observe the patient's progress.

Records serve as reference material for research, improving new approaches to patient care and enhancing professional knowledge.

Lastly, health records are used in quality reviews. Accreditation agencies perform frequent chart audits as part of a quality assurance program to review a nurse's competence and the hospital's standards.

All these help to identify areas that need improvement. Deficiencies can be addressed by providing staff with in-service training to improve the quality of care.