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Encyclopedia > Medical record
A medical record folder being pulled from the records
A medical record folder being pulled from the records

A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care [1][2]. 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. Image File history File links Download high resolution version (3008x1960, 716 KB) File history Legend: (cur) = this is the current file, (del) = delete this old version, (rev) = revert to this old version. ... Image File history File links Download high resolution version (3008x1960, 716 KB) File history Legend: (cur) = this is the current file, (del) = delete this old version, (rev) = revert to this old version. ... Pediatric polysomnography patient Childrens Hospital (Saint Louis), 2006 A patient or invalid is any person who receives medical attention, care, or treatment. ... The medical history of a patient (sometimes called anamnesis [1][2] ) is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis). ... Health care or healthcare is the prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical, nursing, and allied health professions. ... Ethics is a general term for what is often described as the science (study) of morality. In philosophy, ethical behavior is that which is good or right. ... This article is about law in society. ... To meet Wikipedias quality standards, this article or section may require cleanup. ...

Contents

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. [3]. Texas Tech University Health Sciences Center in Lubbock, Texas, USA. A medical school or faculty of medicine is a tertiary educational institution or part of such an institution that teaches medicine. ... It has been suggested that this article or section be merged with residency (medicine). ... Formally introduced in 1993 into the United Kingdoms National Health Service, (NHS), clinical audit is defined as, a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. The key component of clinical audit is... It has been suggested that this article or section be merged with quality assurance. ... To meet Wikipedias quality standards, this article or section may require cleanup. ...


Format

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. An electronic medical record (EMR) is a medical record in digital format. ...


Contents

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[4]. In some places, billing information is considered to be part of the medical record [5].


Demographics

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. A demographic or demographic profile is a term used in marketing and broadcasting, to describe a demographic grouping or a market segment. ... This article concerns the term race as used in reference to human beings. ...


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. The medical history of a patient (sometimes called anamnesis [1][2] ) is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis). ... The term, longitudinal means front-to-back or top-to-bottom as opposed to transverse which means side-to-side. In automotive engineering, the term, longitudinal refers to an engine in which the crankshaft is oriented along the long axis of the vehicle, front to back. ... A disease is any abnormal condition of the body or mind that causes discomfort, dysfunction, or distress to the person affected or those in contact with the person. ... This article needs more context around or a better explanation of technical details to make it more accessible to general readers and technical readers outside the specialty, without removing technical details. ... Growth landmarks are parameters measured in infants, children and adolescents which help gauge where they are on a continuum of normal growth and development. ...

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 (ie occupational exposure to asbestos).
Habits
Various habits which impact health, such as tobacco use, alcohol intake, recreational drug use, 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 preferences.
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 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.

A cardiothoracic surgeon performs a mitral valve replacement at the Fitzsimons Army Medical Center. ... In writing, a report or document characterized by information or other content reflective of inquiry or investigation, tailored to the context of a given situation and audience. ... A cardiothoracic surgeon performs a mitral valve replacement at the Fitzsimons Army Medical Center. ... This does not cite its references or sources. ... A pregnant woman near the end of her term Pregnancy is the carrying of one or more embryos or fetuses by female mammals, including humans, inside their bodies. ... A family in Ouagadougou, Burkina Faso in 1997 A family consists of a domestic group of people (or a number of domestic groups), typically affiliated by birth or marriage, or by analogous or comparable relationships — including domestic partnership, cohabitation, adoption, surname and (in some cases) ownership (as occurred in the... A pedigree chart is a chart which tells one all of the known phenotypes for an organism and its ancestors, most commonly humans, show dogs, and race horses. ... Interpersonal relationships are social associations, connections, or affiliations between two or more people who may interact overtly, covertly, face to face or may remain effectively unknown to each other such as those in a virtual community who maintain anonymity and do not socialize outside of a chat room. ... A community usually refers to a sociological group in a large place or collections of plant or animal organisms sharing an environment. ... This article is about the product manufactured from Tobacco plants (Nicotiana spp. ... Functional group of an alcohol molecule. ... Recreational drug use is the use of psychoactive drugs for recreational rather than medical or spiritual purposes, although the distinction is not always clear. ... The term Exercise can refer to: Physical exercise such as running or strength training Exercise (options), the financial term for enacting and terminating a contract Category: ... In nutrition, the diet is the sum of food consumed by a person or other organism. ... It has been suggested that this article or section be merged with sexual orientation. ... Vaccination is the process of administering weakened or dead pathogens to a healthy person or animal, with the intent of conferring immunity against a targeted form of a related disease agent. ... A scanning electron microscope image of a single neutrophil (yellow), engulfing anthrax bacteria (orange). ...

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 (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: A medical specialist is someone who specializes in a particular field of medicine. ... The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by doctors and other health care providers to write out notes in a patients chart. ...

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 that the patient is experiencing which 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 and examination of the different organ systems, especially ones which might directly be responsible for the symptoms that 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.).

The chief complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medical encounter[1]. See also Medical history Category: ... In a medical encounter, a history of the present illness (HPI) (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain). ... In medicine, the physical examination or clinical examination is the process by which the physician investigates the body of a patient for signs of disease. ... Link title:This article is about the medicinal use. ...

Orders

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 (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 SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by doctors and other health care providers to write out notes in a patients chart. ... Respiratory therapy is an allied health field involved in the treatment of breathing disorders which include chronic lung problems (i. ...


Test results

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. Schematics of shorthand for complete blood count commonly used by physicians. ... Image A: A normal chest X-ray. ... In the NATO phonetic alphabet, X-ray represents the letter X. An X-ray picture (radiograph) taken by Röntgen An X-ray is a form of electromagnetic radiation with a wavelength approximately in the range of 5 pm to 10 nanometers (corresponding to frequencies in the range 30 PHz... Pathology (from Greek pathos, feeling, pain, suffering; and logos, study of; see also -ology) is the study of the processes underlying disease and other forms of illness, harmful abnormality, or dysfunction. ... Brain biopsy A biopsy (in Greek: bios = life and opsy = look/appearance) is a medical test involving the removal of cells or tissues for examination. ... Spirometry (meaning the measuring of breath) is the most common of the Pulmonary Function Tests (PFTs), measuring lung function, specifically the measurement of the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled. ... In the NATO phonetic alphabet, X-ray represents the letter X. An X-ray picture (radiograph) taken by Röntgen An X-ray is a form of electromagnetic radiation with a wavelength approximately in the range of 5 pm to 10 nanometers (corresponding to frequencies in the range 30 PHz...


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. An intensive care unit An Intensive Care Unit (ICU) or Critical Care Unit (CCU) is a specialised facility in a hospital that provides intensive care medicine. ... Informed consent is a legal condition whereby a person can be said to have given consent based upon an appreciation and understanding of the facts and implications of an action. ... ECG may also refer to the East Coast Greenway Lead II An Electrocardiogram (ECG or EKG, abbreviated from the German Elektrokardiogramm) is a graphic produced by an electrocardiograph, which records the electrical voltage in the heart in the form of a continuous strip graph. ... The term pacemaker has multiple meanings: In sports, a pacemaker or pacer is a competitor who enters an athletics race with little or no intention of winning, but purely to set a fast pace for other competitors to follow. ... Chemotherapy is the use of chemical substances to treat disease. ...


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.


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 with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature. The term electronic signature has several meanings. ...


Ownership

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. The National Health Service (NHS) is the publicly-funded healthcare system of the United Kingdom. ... The Department of Health headquarters in Whitehall The Department of Health is a department of the United Kingdom government. ...


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 guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations. Consent (as a term of jurisprudence) is a possible justification against civil or criminal liability. ... The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996. ...

Capacity
When a patient does not have capacity (is not legally able) to make decisions regarding his or her own care, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the comatose, minors (unless emancipated) and patients with incapacitating psychiatric illness or intoxication.
Medical emergency
In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been drafted previously (such as an advance directive)
Research, auditing, and evaluation
Individuals involved in medical research, financial or management audits, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however.
Risk of death or harm
Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (ie, information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the United States Supreme Court case Jaffe v. Redmond[6].

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. The capacity of both natural and artificial persons determines whether they may make binding amendments to their rights, duties and obligations, such as getting married or merging, entering into contracts, making gifts, or writing a valid will. ... A legal guardian is a person who has the legal authority (and the corresponding duty) to care for the personal and property interests of another person, called a ward. ... In medicine, a coma (from the Greek koma, meaning deep sleep) is a profound state of unconsciousness. ... Emancipation of minors is a legal mechanism through which a person below the age of majority gains certain civil rights, generally identical to those of adults. ... Psychiatrist redirects here. ... ... A Living Will, also called Will to Live, Advance Health Directive, or Advance Health Care Directive, is a specific type of power of attorney or health care proxy or advance directive. ... An audit is an evaluation of an organization, system, process, project or product. ... The Supreme Court Building, Washington, D.C. The Supreme Court Building, Washington, D.C., (large image) The Supreme Court of the United States, located in Washington, D.C., is the highest court (see supreme court) in the United States; that is, it has ultimate judicial authority within the United States... Jaffe v. ... The Data Protection Act (DPA) is a United Kingdom Act of Parliament that provides a legal basis and allowing for the privacy and protection of data of individuals in the UK. The act places restrictions on organisations which collect or hold data which can identify a living person. ... See Freedom of information in the United Kingdom for a general discussion of freedom of information legislation throughout the United Kingdom. ...


Destruction

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 patent 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). [7] Harold Frederick Shipman (14 January 1946 – 13 January 2004) was a British general practitioner who was the most prolific known serial killer in British history. ...


Abuses

  • The outsourcing of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data.
  • Falsification of a medical record by a medical professional is a felony in most United States jurisdictions.
  • Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.

Outsourcing entered the business world in the 1980s and often refers to the delegation of non-core operations from internal production to an external entity specializing in the management of that operation. ... For the record label, see Felony Records The term felony is a term used in common law systems for very serious crimes, whereas misdemeanors are considered to be less serious offenses. ...

See also

The medical history of a patient (sometimes called anamnesis [1][2] ) is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis). ... In medicine, the physical examination or clinical examination is the process by which the physician investigates the body of a patient for signs of disease. ... An electronic medical record (EMR) is a medical record in digital format. ... Electronic health record (EHR) with image and document links. ... In the laws of many common law jurisdictions, the concept of legal privilege, or the rule that certain conversations are so private and confidential that they cannot be used as evidence in court, extends to communication between a patient and physician. ...

References

  • ^  UK newspaper article "Government 'Breached Ex-Soldier's Human Rights'" Guardian. October 20th, 2004.

External links

MedlinePlus (medlineplus. ... Electronic Privacy Information Center or EPIC is a public interest research group in Washington D.C.. It was established in 1994 to focus public attention on emerging civil liberties issues and to protect privacy, the First Amendment, and constitutional values. ... This does not cite its references or sources. ... The shamefulness associated with the examination of female genitalia has long inhibited the science of gynaecology. ... The University of Nevada, Reno (Nevada or UNR) is a university located in Reno, Nevada and is known for its programs in agricultural research, animal biotechnology, and mining-related engineering and natural sciences. ...

Organizations dealing with medical records


 
 

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