How can I help make my hospital experience successful?

It is important for patients to provide hospital personnel with all important medical information, such as past illness and medication, so they can provide the care needed for each patient’s unique situation.

What are my responsibilities?

• You are responsible for providing information about your health, including past illness, hospital stays and use of medicine.
  
• You are responsible for asking questions when you do not understand information or instructions.
  
• If you believe you can't follow through with your treatment, you are responsible for telling your doctor.
  
• This hospital works to provide care efficiently and fairly to all patients and the community. You and your visitors are responsible for being considerate of the needs of other patients, staff and the hospital.
  
• You are responsible for providing information for insurance and working with the hospital to arrange payment when needed.
  
• Your health depends not just on your hospital care, but in the long term, on the decisions you make in daily life. You are responsible for recognizing the effect of lifestyle on your personal health.

What is in my medical record?
The medical record tells the story of a patient’s time a Hendrick starting with a history of their medical conditions and ending with the day the leave the hospital. It is the responsibility of the physician to record each thing that happens to a patient while he or she is in the hospital. The physician must be very specific in recording details in the medical record.

A medical record includes:

• information about the patient’s condition
  
• history of illness
  
• progress notes
  
• physicians’ orders
  
• lab results
  
• radiology reports
  
• any other tests
  
• medication received

About Medical Record Coding

Healthcare organizations use coded medical records to measure care quality at hospitals. The organizations decided what records to include in certain quality measurements based on the conditions coded in them.

Codes are the special language of a medical record. Coders use thousands of different code numbers to tell health professionals about each specific condition of the patient based on the information recorded in the record by the physician. Codes help health professionals reviewing the record to easily see all the different conditions affecting a patient based on the code numbers included.

Coders will code conditions strictly based on the information recorded by the physician. The more specific the physician describes a condition, the more specific a code the coder is able to record. For example, there is a general code number for pneumonia, but under the category of pneumonia there are hundreds of more specific code numbers to better describe the type, cause or severity of the pneumonia