Class 12 Health Care Chapter 7 Medical Records

Class 12 Health Care Chapter 7 Medical Records Solutions English Medium As Per AHSEC New Syllabus to each chapter is provided in the list so that you can easily browse through different chapters Class 12 Health Care Chapter 7 Medical Records Question Answer and select need one. Class 12 Health Care Notes Download PDF. AHSEC Class 12 Elective Health Care Question Answer English Medium.

Class 12 Health Care Chapter 7 Medical Records

Also, you can read the NCERT book online in these sections Solutions by Expert Teachers as per Central Board of Secondary Education (CBSE) Book guidelines. AHSEC Class 12 Health Care Textual Solutions are part of All Subject Solutions. Here we have given AHSEC Class 12 Health Care Textbook Solutions English Medium for All Chapters, You can practice these here.

Medical Records

Chapter: 7

EXERCISE

A. Fill in the Blanks:

1. A chronological written account of a patient’s examination and treatment is called a __________.

Ans: Medical record.

2. Documentation of patient care promotes __________ of care throughout 24 hours.

Ans: Continuity.

3. The patient’s medical record is the permanent __________ record.

Ans: Legal.

4. The most common chart used to note deviations in temperature, pulse, and respiration is the __________.

Ans: Graphic chart of T.P.R.

5. Medical records are important for evaluation of the patient and also serve as __________ evidence in negligence cases.

Ans: Legal.

B. Short questions:

1. State any four purposes of documenting medical records.

Ans: (i) Better and evidence-based care.

(ii) Accurate and faster diagnosis.

(iii) Avoid repeating unnecessary investigations.

(iv) Support medico-legal decisions.

2. Mention any four principles of documentation.

Ans: (i) Each entry should have a date and time.

(ii) Correct spelling must be used.

(iii) Documentation should follow chronological order.

(iv) Records must be clear, concise, and legible.

3. What is an Admission Note?

Ans: An admission note documents the patient’s status, reasons for admission, and initial instructions for care. It includes personal details, chief complaints, medical history, allergies, family history, and initial examination results.

4. What is the difference between LAMA and DAMA?

Ans: LAMA (Left Against Medical Advice): Patient leaves suddenly without proper discussion, hospital may not provide discharge summary.

DAMA (Discharged Against Medical Advice): Patient/relatives sign declaration despite risks explained, hospital gives discharge summary.

5. Write any four types of medical records maintained in hospitals.

Ans: (i) Outpatient and Inpatient Records.

(ii) Doctor’s Order Sheet.

(iii) Diet Sheets.

(iv) Consent Forms for Operation and Anesthesia.

C. Long questions: 

1. Explain the purpose and importance of medical documentation.

Ans: Documentation is essential in healthcare for several reasons. It ensures better and evidence-based care and supports accurate, faster diagnosis. It avoids repeating unnecessary investigations and helps in planning personalized treatment. It supports medico-legal and reimbursement decisions. Documentation provides continuity of care across shifts and ensures effective communication among health professionals. It also promotes auditing, which improves the quality of care. Proper documentation serves as permanent legal records and protects healthcare professionals in case of disputes. Thus, documentation improves public health, reduces costs, and ensures safety and accountability.