Medical record
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
The terms are used for the written, physical and digital records that exist for each individual patient and for the body of information found therein.
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association.
Because many consider the information in medical records to be sensitive private information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.
Uses
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes, preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
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.
Electronic medical records could also be studied to quantify disease burdens – such as the number of deaths from antimicrobial resistance – or help identify causes of, factors of and contributors to diseases, especially when combined with genome-wide association studies. For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized forms to ensure patients' privacy is maintained.
Contents
A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further information varies with the individual medical history of the patient.The contents are generally written with other healthcare professionals in mind. This can result in confusion and hurt feelings when patients read these notes. For example, some abbreviations, such as for shortness of breath, are similar to the abbreviations for profanities, and taking "time out" to follow a surgical safety protocol might be misunderstood as a disciplinary technique for children.
Media applied
Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note, with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research.
Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.
Medical history
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 state. It includes several subsets detailed below.;Surgical history
;Obstetric history
;Medications and medical allergies
;Family history
;Social history
;Habits
;Immunization history
;Growth chart and developmental history
Medical encounters
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 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, which includes a problem list of diagnoses or a "SOAP" method of documentation for each visit. Each encounter will generally contain the aspects below:;Chief complaint
;History of the present illness
;Physical examination
;Assessment and plan
Orders and prescriptions
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.Progress notes
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. They are kept in chronological order and document the sequence of events leading to the current state of health.Test results
The results of testing, such as blood tests radiology examinations, pathology, or specialized 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.Other information
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, 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.Administrative issues
Medical records are legal documents that can be used as evidence via a subpoena duces tecum, and are thus subject to the laws of the country/state in which they are produced. As such, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself.In 2009, Congress authorized and funded legislation known as the Health Information Technology for Economic and Clinical Health Act to stimulate the conversion of paper medical records into electronic charts. While many hospitals and doctor's offices have since done this successfully, electronic health vendors' proprietary systems are sometimes incompatible.
Demographics
s include patient information that 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 occupation. It also contains information regarding the patient's health insurance. It is common to also find emergency contact information located in this section of the medical chart.Production
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 out with a single line and initialed by the author.Orders and notes must be signed by the author. Electronic versions require an electronic signature.
Ownership of patient's record
Ownership and keeping of patient's records varies from country to country.US law and customs
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 per the Health Insurance Portability and Accountability Act. Patients have the right to ensure that the information contained in their record is accurate, and can petition their health care provider to amend factually incorrect information in their records.There is no consensus regarding medical record ownership in the United States. Factors complicating questions of ownership include the form and source of the information, custody of the information, contract rights, and variation in state law. There is no federal law regarding ownership of medical records. HIPAA gives patients the right to access and amend their own records, but it has no language regarding ownership of the records. Twenty-eight states and Washington, D.C., have no laws that define ownership of medical records. Twenty-one states have laws stating that the providers are the owners of the records. Only one state, New Hampshire, has a law ascribing ownership of medical records to the patient.