Documentation of Health Aspects of an Individual Report

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Introduction

I will utilize this report to offer a description of the steps I took to access my past health record. Personal health records are important in the contemporary world where personalized care is critical. Documentation of health aspects of an individual is important in improving health outcomes (Duan, Street & Xu, 2011). In the recent past, I encountered migraine headache that forced me to change my personal physician. My current physician encouraged me to access my previous health record so that he would offer better care, which would be greatly impacted by my health history.

Approach

I was aware that my health record was in the form of softcopy because my former physician worked in a facility that used information management system. I planned to visit the facility and request the front desk staff to schedule an appointment with a general practitioner in charge of health records. On 5 August 2014, I visited the facility and asked the front office staff whether I could speak to the doctor in charge of health records. I was happy when I was informed that I would not need to seek an appointment because he was not busy at that time.

Dialogue (physician’s office)

5 August 2014 at 9:30am

S: Student

D: Doctor

S: Good morning doctor.

D: Good morning. How may I help you?

S: I am interested in accessing my healthcare record that is in this health facility.

D: Why are you in need of your healthcare record?

S: I have a new physician who does not work in your facility and he would like to go through my health record so that he may have the right information as he attempts to treat me with regard to migraine headache.

D: Sure, you need to have it. Can I have your name?

(I spell out my name as he typed on the computer).

Kindly come closer so that you may access your record. Confirm whether the information is yours.

S: I confirm.

D: Let me send you the information in your email as well as print a hardcopy for you. (He asks me my email address as he requests his secretary to print the hard copy).

I think you have all that you needed. Any other assistance?

S: What a quick process? That is all I needed. Thank you so much.

D: You are welcome.

Summary

The process took approximately one hour. The response of the general doctor in charge of records was very encouraging. In fact, he made the process take shorter time because I was not requested to make further contacts. The only information requested was my name. I was given my health record that contained previous diagnostic tests, results and medications. In addition, the record contained previous appointments and physician’s notes. I learned that computerization of health records is important in facilitating care. I was surprised because I had thought that it would take a relatively long period.

Analysis

I was very happy to receive my record in my first attempt. It was an experience that I would wish to repeat in the future. The physician was prepared to handle my request and that is why the process took a relatively short period.

Recommendations

With regard to individuals, I would request them to know the right departments and/or healthcare personnel that would be important in accessing health records. I would ask caregivers to be aware of the right approaches that would be used to retrieve health records of patients. The awareness would include a thorough understanding of the use of computers (Duan et al., 2011). Based on my experience and the knowledge I have gained in this course, I would assert that computerization of healthcare information is essential in improving healthcare outcomes. In fact, legislation should be aimed at enabling more hospitals to use computers to manage patients’ information.

Reference

Duan, L., Street, W. N., & Xu, E. (2011). Healthcare information systems: data mining methods in the creation of a clinical recommender system. Enterprise Information Systems, 5(2), 169-181.

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IvyPanda. 2022. "Documentation of Health Aspects of an Individual." April 13, 2022. https://ivypanda.com/essays/documentation-of-health-aspects-of-an-individual/.

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