Example of Medical Record

Science   /   by admin   /   July 04, 2021

A medical record It is a document in which the doctor records the data and circumstances that his patients keep.

The medical record contains as elements the following:

  • Name
  • Name of family member or responsible person
  • Personal habits
  • Medical information
  • Date
  • Signature and where appropriate
  • Stamp.

Example of medical record:

Mendoza Office
Health record number 235984
Av. Montes, Col Robledo Mexico Federal District

Name of patient: Mariano Landeros Cordero
Name of the responsible person: Maria Landeros Padilla

  • Information of the person responsible: _________________________
  • Relationship: Mother________

Personal habits:

  1. Smoke (yeah)
  2. You exercise (No)
  3. Consume drugs (no)

Medical information:

Have a systemic disease (no)
Have a chronic disease (no)
He suffers from an acute illness (Yes)

Specify: Lung damage from COPD

Date: August 31, 2012

_________________
Firm

Another example of a medical record:

Robledo Urban Hospital
Highway Mexico Pachuca Kilometer 23

Name of patient: Rodolfo Carrillo Cañedo
Name of the responsible person: Lisa Fuentes Mateo

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  • Information of the person responsible: _________________________
  • Relationship: Marriage_____________

Personal habits:

  1. Smokes (no)
  2. He exercises (Yeah)
  3. Consume drugs (no)

Medical information:
Have a systemic disease (no)
Have a chronic disease (no)
He suffers from an acute illness (Yes)

Specify: Skin cut injury, requires 16 stitches

Date: August 31, 2012

_________________
Firm

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