A hospital information system stores each patient’s medical record, including personal details such as name, date of birth and physical address. The system also includes medical history, test results and consultation reports, says Emblem Health.
A hospital information system contains all information that is required to identify a patient, including contact details, marital status, age, sex, current occupation and place of employment. The system also includes an outline of the patient’s medical condition as well as the current medication being administered. Past medical history for patients seen several times, as well as known medical allergies and reactions, are also be documented. The system must indicate all diagnoses as well as treatment plans that are consistent with the diagnoses, notes AmeriHealth. Medical records for children must include the types of immunization administered.
Medical information contained in the system also includes previous telephone communication encounters, and results of all physical examinations carried out on each patient. It should also indicate all clinical findings and laboratory test results, as well as details of scheduled visits and past referrals, states the Illinois Department of Human Services. Information stored on female patients often includes any contraceptive method being used as well as any previous prenatal and birth information.