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A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care . The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal. Although medical records are traditionally compiled and stored by health care providers, personal health records maintained by individual patients have become more popular in recent years.
Additional recommended knowledge
The information contained in the medical record allows health care providers to provide continuity of care to individual patients. The medical record also serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care, assisting in protecting the legal interest of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient. In addition, the medical record may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research. Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems. .
Traditionally, medicals records have been written on paper and kept in folders. These folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues. Active records are usually housed at the clinical site, but older records (eg those of the deceased) are often kept in separate facilities.
The advent of electronic medical records has changed not only the format of medical records, but has increased accessibility of files.
Although the specific content of the medical record may vary depending upon specialty and location, it usually contains the patient's identification information; the patient's health history (what the patient tells the health care providers about his or her past and present health status); and the patient's medical examination findings (what the health care providers observe when the patient is examined). Other information may include lab test results; medications prescribed; referrals ordered to health care providers; educational materials provided; and what plans there are for further care, including patient instruction for self-care and return visits. In some places, billing information is considered to be part of the medical record .
Demographics include information regarding the patient which is not medical in nature. It is often information to locate the patient including identifying numbers, addresses, and contact numbers. It may contain information about race and religion as well as workplace and type of occupational information. It may also contain information regarding the patient's health insurance. It is common to also find emergency contacts located in this section of the medical chart.
The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below.
Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (ie when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a "SOAP" method of documentation for each visit. Each encounter will generally contain the aspects below:
Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health care team (doctors, nurses, dietitians, clinical pharmacists, respiratory therapists, etc). They are kept in chronological order and document the sequence of events leading to the current state of health.
The results of testing, such as blood tests (eg complete blood count) radiology examinations (eg X-rays), pathology (eg biopsy results), or specialized testing (eg pulmonary function testing) are included. Often, as in the case of X-rays, a written report of the findings is included in lieu of the actual film.
Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.
Medical records are legal documents and are subject to the laws of the country/state in which they are produced. As such, there is great variability in rule governing production, ownership, accessibility, and destruction.
In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature.
In the United States, the data contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record. Therefore, patients have the right to ensure that the information contained in their record is accurate. Patients can petition their health care provider to remedy factually incorrect information in their records.
In the United Kingdom, the NHS's medical records belong to the Department of Health.
In the United States, the most basic rules governing access to a medical record dictate that only the patient and the health care providers directly involved in delivering care have the right to view the record. The patient, however, may grant consent for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.
In the United Kingdom, the Data Protection Acts and later the Freedom of Information Act 2000, gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g. information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's well-being (eg some psychiatric assessments). Also the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.
In general, entities in possession of medical records are required to maintain those records for a given period of time. In the United Kingdom, medical records are required for the lifetime of a patient and legally for as long as the time that complaint action can be brought. Generally in the UK any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patient’s death to investigate illnesses within a community (e.g. industrial or environmental disease or even of doctors committing murders, e.g. Harold Shipman).
Organizations dealing with medical records
|This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Medical_record". A list of authors is available in Wikipedia.|