Medical Records and Phlebotomy Notes

Flashcards created from notes about medical records, phlebotomy basics, and key definitions related to patient treatment.

What is the purpose of the registration/admission form in medical records?

To record important information such as the patient's name, address, and insurance information.

What does a patient's medical history include?

Critical questions regarding the patient's past health history.

What is the significance of the treatment consent form?

It includes a statement that the patient has been informed of the treatment plan, side effects, and negative outcomes.

Define sexual orientation.

A person's pattern of emotional, romantic, and sexual attraction to a particular gender.

What does gender identity refer to?

A person's sense of where they belong on a continuum of masculine to feminine traits.

Why is a plan of treatment important in medical records?

It helps establish a plan for recovery and provides the patient with instructions to follow.

What does the 'plan of treatment' form record?

The provider records the details regarding treatment on this form.