Final answer:
A patient's medical record must include diagnostic and therapeutic orders, medical history, and informed consent. Policies should address treatment costs, quality of life, and privacy protection. It's essential to determine when informed consent is necessary and how to ensure it is truly informed.
Step-by-step explanation:
The patient's medical record or chart must include several essential components to ensure comprehensive care and legal compliance. Among these, diagnostic and therapeutic orders, the medical history, and informed consent are crucial. Diagnostic and therapeutic orders provide a record of the treatments and tests that have been prescribed to the patient. The medical history contains a detailed account of the patient's past health issues, surgeries, treatments, and family health history, which are vital for making informed decisions about care. Lastly, informed consent is necessary before proceeding with any procedure or treatment, ensuring that the patient understands and agrees to the potential risks and benefits associated with their care.
When developing policies around health records, several questions must be addressed:
- How can we balance the costs of treatments and diagnoses with maintaining high patient quality of life while safeguarding privacy?
- What measures are sufficient to protect individual privacy in the management of health records?
- In what scenarios is informed consent mandatory, and how do we ensure it is sufficiently informed?