Where in the record would you find this information?

Contact a health care facility (hospital, nursing home, physician’s offi ce, or other organization) to ask permission to view a sample of the health records they maintain. Answer the following questions for each record:

a. What is the primary reason (or condition) for which the patient was seen?

b. How long has the patient had this condition?

c. Did the patient have a procedure performed? If so, what procedure(s) was (were) done?

d. Did the patient experience any complications? If so, what were they?

e. How does the physician’s initial assessment of the patient compare with the nurse’s initial assessment? Where in the record would you find this information?

f. To where was the patient discharged?

g. What were the patient’s discharge orders or instructions? Where in the record should you find this information?