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For the New York journal published by the Washington Institute of Medicine, see Medical Record (journal). The Medical Record: A Weekly Journal of Medicine and Surgery was founded in 1866 by George Frederick Shrady who was its first editor-in-chief
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. A patient is any person who receives medical attention care or treatment. The medical history or Anamnesis of a Patient is information gained by a Physician or other healthcare professional by asking specific questions Health care is the prevention treatment and management of illness and the preservation of mental health through the services offered by the medical, Nursing 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. Ethics is a major branch of Philosophy, encompassing right conduct and good life Law is a system of rules enforced through a set of Institutions used as an instrument to underpin civil obedience politics economics and society 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. A personal health record or PHR is typically a health record that is initiated and maintained by an individual

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. Education encompasses both the Teaching and Learning of Knowledge, proper conduct, and technical competency Medical education A medical school or faculty of medicine is a Tertiary educational institution—or part of such an institution—that teaches Medicine Residency is a stage of graduate medical training. A resident physician or resident is a person who has received a Medical degree ( MD Clinical audit is the process formally introduced in 1993 into the United Kingdom 's National Health Service (NHS and is defined as "a quality In Engineering and Manufacturing, quality control and quality engineering are involved in developing systems to ensure products or services 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. A personal health record or PHR is typically a health record that is initiated and maintained by an individual [1].

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. 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[2]. A Medication Administration Record or MAR is the report that serves as a legal record of the Drugs administered to a Patient at a facility by a nurse In some places, billing information is considered to be part of the medical record [3].

Demographics

Demographics include patient information that is not medical in nature. Demographics or demographic data refers to selected population characteristics as used in government Marketing or opinion research or the Demographic profiles 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. The term race or racial group usually refers to the concept of categorizing Humans into Populations or groups on the basis of various sets A religion is a set of Tenets and practices often centered upon specific Supernatural and moral claims about Reality, the Cosmos 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.

Medical history

The medical history is a longitudinal record of what has happened to the patient since birth. The medical history or Anamnesis of a Patient is information gained by a Physician or other healthcare professional by asking specific questions It chronicles diseases, major and minor illnesses, as well as growth landmarks. A disease is an abnormal condition of an organism that impairs bodily functions and can be deadly Illness (sometimes referred to as ill-health or ail) can be defined as a state of poor Health. Growth landmarks are Parameters measured in Infants, Children and Adolescents which help gauge where they are on a Continuum of normal 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. Surgery (from the χειρουργική cheirourgikē, via chirurgiae meaning "hand work" is a medical specialty that uses operative manual and instrumental It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did. In writing a report is a document characterized by information or other content reflective of inquiry or investigation which is tailored to the context of a given situation and audience Surgery (from the χειρουργική cheirourgikē, via chirurgiae meaning "hand work" is a medical specialty that uses operative manual and instrumental
Obstetric history
The obstetric history lists prior pregnancies and their outcomes. Obstetrics (from the Latin obstare, "to stand by" is the surgical speciality dealing with the care of a woman and her offspring during Pregnancy Pregnancy ( Latin graviditas) is the carrying of one or more offspring known as a Fetus or Embryo, inside the Uterus of a Female 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). Family denotes a group of People affiliated by consanguinity affinity or co-residence 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. A Pedigree Chart is a chart which tells someone all of the known Phenotypes for an Organism and its Ancestors most commonly humans show Dogs 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. An interpersonal relationship is a relatively long-term association between two or more people It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. In biological terms a community is a group of interacting Organisms sharing an environment. 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 (i. e. , 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. Tobacco is an Agricultural product recognized as an addictive drug processed from the fresh Leaves of plants in the genus Nicotiana. In Chemistry, an alcohol is any Organic compound in which a Hydroxyl group ( - O[[hydrogen H]]) is bound to a Carbon Recreational drug use is the use of Psychoactive drugs for Recreational purposes rather than for work, medical or spiritual purposes This article is primarily about the human diet For a discussion of animal diets see List of feeding behaviours. This section may also include more intimate details such as sexual habits and sexual preferences. Sexual orientation is believed to refer to "an enduring pattern of emotional romantic and/or sexual attractions to men women or both sexes
Immunization history
The history of vaccination is included. Vaccination is the administration of Antigenic material (the Vaccine) to produce immunity to a disease Any blood tests proving immunity will also be included in this section. An immune system is a collection of mechanisms within an Organism that protects against Disease by identifying and killing Pathogens and Tumor
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.

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. A specialty in Medicine is a branch of medical science other than General practice. 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. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by doctors and other Each encounter will generally contain the aspects below:

Chief complaint
This is the problem that has brought the patient to see the doctor. The Chief Complaint (CC or termed Presenting Complaint (PC in the UK is a concise statement describing the Symptom, problem Condition, Diagnosis 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. 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
Physical examination
The physical examination is the recording of observations of the patient. Physical examination or clinical examination is the process by which a Health care provider investigates the body of a Patient for signs This includes the vital signs and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing. Vital signs are measures of various physiological statistics often taken by Health professionals in order to assess the most basic body functions
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. ).

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). The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by doctors and other Respiratory Therapy is categorized as an Allied health profession in the United States and Canada 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 (e. g. , complete blood count) radiology examinations (e. A complete blood count ( CBC) also known as full blood count ( FBC) or full blood exam ( FBE) or blood panel, is Radiology is the medical specialty directing Medical imaging technologies to diagnose and treat diseases g. , X-rays), pathology (e. X-radiation (composed of X-rays) is a form of Electromagnetic radiation. Pathology (from Greek grc πάθος pathos, "fate harm" and grc -λογία -logia) is the study and g. , biopsy results), or specialized testing (e. A biopsy (in Greek: βίος life and όψη look/appearance is a Medical test involving the removal of cells or tissues g. , pulmonary function testing) are included. Spirometry (meaning the measuring of breath) is the most common of the Pulmonary Function Tests (PFTs measuring Lung function specifically the measurement Often, as in the case of X-rays, a written report of the findings is included in lieu of the actual film. X-radiation (composed of X-rays) is a form of Electromagnetic radiation.

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 (ICU critical care unit (CCU intensive therapy unit or intensive treatment unit (ITU is a specialized department used in 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 implications For other uses see Pacemaker (disambiguation A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural pacemaker Chemotherapy, in its most general sense refers to treatment of disease by chemicals that kill cells specifically those of micro-organisms or Cancer.

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. The United States of America —commonly referred to as the 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. The term electronic signature has several meanings Among the more expansive is that given by US law influenced by ABA committee white papers and the uniform law promulgated

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. The United States of America —commonly referred to as the 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 United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom, the UK or Britain,is a Sovereign state located The Department of Health (DH is a department of the United Kingdom government but with responsibility for government policy for England alone on Health

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 United States of America —commonly referred to as the The patient, however, may grant consent for any person or entity to evaluate the record. Consent as a term of jurisprudence is a possible defence (an Excuse or justification against civil or criminal liability 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 Health Insurance Portability and Accountability Act ( HIPAA) was enacted by the U 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 guardian is designated (either through next of kin or by action of a court of law if no kin exists). Discussion As an aspect of the Social contract between a state and its Citizens the state adopts a role of protector to the weaker and more vulnerable members 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 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. In Medicine, a coma (from the Greek koma, meaning deep sleep is a profound state of Unconsciousness. Emancipation of minors is a legal mechanism by which a child is freed from control by their parent(s/guardian(s and the parent(s/guardian(s is/are freed from any and all responsibility Psychiatry is a medical specialty which exists to study, prevent, and treat Mental disorders in Humans Psychiatric Intoxication is the state of being affected by one or more psychoactive drugs.
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 previously drafted (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. Advance health care directives or advance directives are instructions given by individuals specifying what actions should be taken for their health in the event that they are The most general definition of an audit is an evaluation of a person organization system process project or product 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 (i. e. , 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[4]. The Supreme Court of the United States is the highest judicial body in the United States and leads the federal judiciary. In Jaffee v Redmond,, the Supreme Court created a Psychotherapist-patient privilege in the Federal Rules of Evidence.

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. The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom, the UK or Britain,is a Sovereign state located The Data Protection Act ( DPA) is a United Kingdom Act of Parliament. See Freedom of information in the United Kingdom for a general discussion of Freedom of information legislation throughout the United Kingdom. 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 wellbeing (e. g. , 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.

Destruction

In general, entities in possession of medical records are required to maintain those records for a given period. In the United Kingdom, medical records are required for the lifetime of a patient and legally for as long as that complaint action can be brought. The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom, the UK or Britain,is a Sovereign state located 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 deaths at the hands of doctors committing murders, as in the Harold Shipman case). Harold Frederick "Fred" Shipman (14 January 1946 &ndash 13 January 2004 was an English General practitioner and convicted Serial killer [5]

Abuses

See also

References

External links

Organizations dealing with medical records

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