Describe the parts of a clinical record?

Question:

Answers:
Patient's record would typically contain:

Record Number (& volume number if applicable)

Demographic Data:
Name (Family name, First name) +/- title etc.
Age (Date of Birth)
Address + contact details
Family/Next Of Kin

Insurance details

Initial visit ... and then chronological documentation of subsequent visits. This stuff will vary depending on whether you are talking about dentists/doctors/vets/etc.

I'm a doctor so mostly we would do (and many may change the order of things around a bit):
Presenting Complaint
History of Presenting Complaint
Past Medical History
Allergies
Medications
Social Habits
Family Pedigree particularly if there are certain diseases in the family
Examination - vital signs - sometimes height and weight too
First visit would have Full Screening Examination

Reports and Results (letters, tests, etc)

I imagine dentists would do a similar thing, more focussed on dental matters. I've seen my dentist draw a picture representation of my teeth and make notes all over it.

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