Medical record
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A medical record, health record, or medical chart is a systematic documentation of a patient's individual 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.
[edit] Purpose
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.[2].
[edit] Contents
Basically a patient's individual medical record shall identitfy the patient and shall contain the information obtained with a certain case and shall refer to past cases with the very same patient.
[edit] Basic contents
The information recorded with a personal health record could start with
* Name, birth date, residence and emergency contact
* Sex, Blood type
* Date of last physical examination
* Dates and results of tests and screenings
* Major illnesses and surgeries, with dates
* List of medication, dosages and duration of prescription
* Any allergies
* Any chronic diseases
* Any history of illnesses in the family
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.[3] In some places, billing information is considered to be part of the medical record.[4]
[edit] Format
Traditionally, medical 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 (e.g., those of the deceased) are often kept in separate facilities.
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.
[edit] 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 states. It includes several subsets detailed below.
- Surgical history
- The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.
- Obstetric history
- The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.
- Medications and medical allergies
- The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies.
- Family history
- The family history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.
- Social history
- The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).
- Habits
- Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientation.
- Immunization history
- The history of vaccination is included. Any blood tests proving immunity will also be included in this section.
- Growth chart and developmental history
- For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth and longitudinal charting and can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.
[edit] 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 (i.e., 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:
- Chief complaint
- This is the problem that has brought the patient to see the doctor. Information on the nature and duration of the problem will be explored.
- History of the present illness
- A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
- Physical examination
- The physical examination is the recording of observations of the patient. This includes the vital signs , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.
- Assessment and plan
- The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).
[edit] 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.
[edit] 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 (doctors, nurses, physical therapists, 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.
[edit] Test results
The results of testing, such as blood tests (e.g., complete blood count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., 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.
[edit] 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 (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.
There are several information needed to be recorded while tracing state of patient's daily health:
1. Vital Signs: Body Temperature, Pulse Rate(Heart Rate), Blood Pressure and Respiratory Rate.
2. Intake: Medication, Fluid, Nutrition, Water and Blood, etc.
3. Output: Blood, Urine, Excrement, Vomitus and Sweat, etc.
4. Observation on Pupil size.
5. Capability of four limbs of body
[edit] Administrative issues
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.
[edit] Demographics
Demographics 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 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.
[edit] 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.
[edit] Informational self-determination
The informational self-determination is a basic human right. Hence the patient's record belongs to the patient.
[edit] Ownership for patient's record
Ownership and keeping of patient's records varies from country to country.
[edit] US law and customs
In the United States, the data contained within the medical record belongs to the patient [citation needed], whereas the physical form the data takes belongs to the entity responsible for maintaining the record (Health Insurance Portability and Accountability Act)[citation needed]. Therefore, patients have the right to ensure that the information contained in their record is accurate[citation needed]. Patients can petition their health care provider to remedy factually incorrect information in their records.[citation needed]
[edit] UK law and customs
In the United Kingdom, ownership of the NHS's medical records belong to the Department of Health,[2] and this is taken by some to mean copyright also belongs to the authorities.[3]
[edit] German law and customs
In Germany ownership of patient's records is not explicitly codifed. Hence traditional keeping of patient's records is with the hopitals and the practitioners. There is no comprehensive data set containing all information on one patient in one file defined yet. Discussion on proper identifying the patient is based on social security number, while discussion on data cards (Gesundheitskarte) containing just identification or more information on health status is continuing since more than a decade (2010). However public discussion on informational self determination will speed up. This may lead to change of concepts within the current century. Hence it is a matter of safety for the individual's health to stay with this status quo as long as no appropriate legislation will set new standards.
[edit] Accessibility
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 the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.
- Capacity
- When a patient does not have capacity (is not legally able) to make decisions regarding his or her own care, a legal guardia
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