The terms medical records , medical records , and medical charts are used interchangeably to illustrate the systematic documentation of a single patient's medical history and treatment at all times in one jurisdiction of certain health care providers. The medical records cover the various types of "records" that enter from time to time by health care professionals, medical observations and administration records of drugs and therapies, orders for drug delivery and therapy, 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 license or certification requirement.
This term is used for both physical folders that exist for each patient and for the information body found in it.
Medical records have traditionally been compiled and maintained by healthcare providers, but progress in online data storage has led to the development of self-managed personal health records (PHRs), often on third party websites. This concept is supported by the US national healthcare administration entity and by AHIMA, the American Health Information Management Association.
Because many see information in medical records as sensitive personal information covered by expectations of privacy, many ethical and legal issues are involved in their maintenance, such as third party access and proper storage and disposal. Although storage equipment for medical records generally belongs to health care providers, records are actually considered in most jurisdictions to belong to patients, who may obtain copies upon request.
Video Medical record
Usage
The information contained in the medical record allows the health care provider to determine the patient's medical history and provide the informed care. The medical record serves as a repository center for planning patient care and documenting communication between patients and healthcare providers and professionals who contribute to patient care. The purpose of the improvement of the medical record is to ensure compliance documentation with institutional, professional or governmental regulations.
Traditional medical records for hospitalization may include entry records, on-service records, progress notes (SOAP notes), pre-operative records, operating records, post-operative notes, procedure notes, delivery notes, postpartum notes, and debit records.
Personal health records combine many of the above features with portability, allowing patients to share medical records across service providers and health care systems.
Maps Medical record
Contents
The patient's individual medical record identifies the patient and contains information about the patient's case history on a particular provider. Health records and every variant of traditional paper files stored electronically contains the identification of the right patient. Further information varies with patient's individual medical history.
Media applied
Traditionally, medical records written on paper and stored in folders are often divided into sections for each type of record (progress notes, sequence, test results), with new information added to each section in chronological order. Active notes are usually stored on clinical sites, but older records are often archived offsite.
The advent of electronic medical records not only changed the format of medical records but also improved file accessibility. The use of individual medical record records, in which records are deposited on each patient based on the name and type of illness originating from the Mayo Clinic due to the desire to simplify patient tracking and allow for medical research.
Maintenance of medical records requires security measures to prevent unauthorized access or damage to recordings.
Medical history
Medical history is a longitudinal record of what has happened to the patient from birth. It chronicles diseases, diseases big and small, as well as growth landmarks. This gives the doctor a sense of what has happened before to the patient. As a result, it can often provide clues to current disease conditions. This includes some of the sub-sections described below.
- History of surgery
- The history of surgery is a history of surgery performed for the patient. It may have an operating date, surgical report, and/or a detailed narration of what the surgeon is doing.
- History of Midwifery
- Obstetric history lists previous pregnancies and results. It also includes complications from this pregnancy.
- Medicines and medical allergies
- The medical record may contain a summary of current and previous patient medications as well as medical allergies.
- Family history
- Family history lists the health status of immediate family members as well as the cause of their death (if known). It may also be a list of common illnesses in the family or only found in one sex or another. This may also include a genealogy chart. It is a valuable asset in predicting some outcomes for patients.
- Social history
- Social history is a chronicle of human interaction. It tells about the patient's relationship, his career and his training, and his religious training. It will be helpful for the doctor to know what kind of support the patient might expect during a major illness. This may explain the patient's behavior in relation to illness or loss. It may also provide clues about the cause of the disease (eg occupational exposure to asbestos).
- Habit
- Health-related habits such as tobacco use, alcohol intake, exercise, and diet are noted, often as part of social history. This section may also include more intimate details such as sexual habits and sexual orientation.
- Immunization history
- Vaccination history is included. Any blood test that proves immunity will also be included in this section.
- Growth chart and development history
- For children and adolescents, a chart documenting growth as comparing with other children of the same age is included, so that health care providers can keep up with child growth over time. Many diseases and social pressures can affect growth, and longitudinal mapping may provide clues to the underlying disease. In addition, a child's behavior (such as speaking time, walking, etc.) as it compares with other children of the same age is documented in the medical record for the same reasons as growth.
Medical meeting
In medical records, individual medical meetings are characterized by a discrete summary of a patient's medical history by a physician, practitioner nurse, or physician's assistant and may take several forms. Documentation of hospital admissions (ie, when a patient requires hospitalization) or consultation by a specialist often takes the full form, details the overall health and previous health care. Regular visits by a provider that is familiar to the patient, however, may take a shorter form such as problem-oriented medical records (POMR), which includes a list of diagnostic problems or the "SOAP" method of documentation for each visit. Each meeting generally contains the following aspects:
- Primary complaint
- This is a major problem (traditionally called a complaint) that has taken the patient to see another doctor or doctor. Information on the nature and duration of the problem will be explored.
- Current medical history
- Exploring details of symptoms experienced by patients who have caused patients to seek medical attention.
- Physical check
- Physical examination is a record of patient observation. These include vital signs, muscle strength and examination of different organ systems, especially those that may be directly responsible for the symptoms experienced by the patient.
- Assess and plan
- Assessment is the written sum of the most likely causes of the current series of patient symptoms. This plan documents the expected actions to address symptoms (diagnosis, treatment, etc.).
Orders and recipes
Orders written by the medical provider are included in the medical record. It details instructions given to other members of the health care team by the major provider.
Advance note
When a patient is hospitalized, daily updates are incorporated into medical records documenting clinical changes, new information, etc. It often takes the form of SOAP notes and is included by all members of the health care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are stored in chronological order and documenting the sequence of events leading to the current state of health.
Test results
Test results, such as blood tests (eg, full blood count) radiological examinations (eg, X-rays), pathology (eg, biopsy results), or special testing (eg, lung 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.
More information
Many other items are stored differently in medical records. Patient digital images, flowsheets from intensive care/intensive care units, informed consent forms, ECG tracking, output from medical devices (such as pacemakers), chemotherapy protocols, and many other important pieces of information form part of the records depending on the patient. and a series of diseases/treatments.
Administrative issues
Medical records are legal documents that can be used as evidence through a court order, subject to the laws of the country/country where they are produced. Thus, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy about the evidence that verifies the facts, or the absence of facts in the record, regardless of the medical record itself.
Demographics
Demographics include non-medical patient information. Often information to find the patient, including identifying the number, address, and contact number. It may contain information about race and religion as well as workplace and occupation. It also contains information about 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, a written record must be marked with the date and time and written with a pen that can not be removed without the use of corrective paper. Errors in records should be strikethrough one line (so the original entry can still be read) and initialed by the author. Orders and notes must be signed by the author. Electronic versions require electronic signatures.
Possession of patient records
The ownership and storage of patient records varies from country to country.
US customs and laws
In the United States, the data is contained in the patient's medical record, while the physical form of data taken belongs to the entity responsible for keeping records per Portability Health Insurance and Accountability Act. Patients have the right to ensure that the information contained in their records is accurate, and may petition their health care providers to change factual information incorrectly in their records.
There is no consensus on ownership of medical records in the United States. Factors that complicate the question of ownership include form and source of information, custody of information, contract rights, and variations in state law. There is no federal law regarding ownership of medical records. HIPAA gives patients the right to access and modify their own records, but has no language on ownership of records. Twenty-eight states and Washington D.C. does not have laws that determine ownership of medical records. Twenty-one countries have laws that state that the provider is the owner of the record. Only one state, New Hampshire, has laws that regulate ownership of medical records to patients.
Canadian law and custom
Under Canadian federal law, the patient has information contained in the medical record, but the health care provider has the record itself. The same goes for nursing homes and dental records. In cases where the provider is a clinic or hospital employee, it is the employer who owns the ownership of the records. By law, all providers must keep medical records for a period of 15 years after the last entry.
The precedent for the law was the 1992 Canadian Supreme Court ruling in McInerney v MacDonald. In the verdict, the request by the doctor, Dr. Elizabeth McInerney, who challenged a patient's access to her own medical records was denied. Patient, Margaret MacDonald, won a court order granting her full access to her own medical records. This case is complicated by the fact that the records are electronic and contain information provided by other providers. McInerney stated that he has no right to release a recording that he himself is not a writer. The court decided otherwise. Legislation is followed, codifying into law the principles of decision. Legislation which regards the provider as the owner of medical records, but requires access to the records given to the patient itself.
English law and custom
In the UK, the NHS medical record ownership in the past is generally described as belonging to the Secretary of State for Health and this is considered by some to mean copyright also belongs to the authorities.
German German law and custom
In Germany, a relatively new law, set in 2013, strengthens the rights of patients. This states, among other things, the official duty of medical personnel to document patient care either in hard copy or in electronic patient records (EPR). This documentation should be conducted on a timely basis and includes any and all forms of treatment received by the patient, as well as other necessary information, such as patient case history, diagnosis, findings, treatments, treatments and their effects, surgical interventions and effects, and informed consent. Information should include almost everything that is important functionally for the truth, but also for future treatment. This documentation should also include medical reports and should be filed by a treating doctor for at least 10 years. The law clearly states that these notes are not only memory devices for doctors, but should also be kept for patients and should be presented on request.
In addition, electronic health insurance cards are issued in January 2014 applicable in Germany (Elektronische Gesundheitskarte or eGK), but also in other member countries of the European Health Insurance Card. It contains data such as: the name of the health insurance company, the validity period of the card, and personal information about the patient (name, date of birth, sex, address, health insurance number) as well as information about the patient's insurance status and additional fees. In addition, it may contain medical data if approved by the patient. This data may include information on emergency care, prescriptions, electronic medical records, and electronic doctor letters. However, due to the limited storage space (32kB), some information is stored on the server.
Accessibility
United States
In the United States, the most basic rules governing access to medical records state that only patients and health care providers are directly involved in providing care that has the right to view the recordings. Patients, however, may give consent to any person or entity to evaluate records. The complete rules on access and security for medical records are set out under the Health Insurance Portability and Accountability Act (HIPAA) guidelines. Rules become more complicated in special situations.
- Capacity
- When a patient does not have the capacity (unable to legally) to make decisions about his own care, a legal guardian is appointed (either through the immediate family or by court action if no relatives). Legal guardians have the ability to access medical records to make medical decisions on behalf of patients. Those who do not have the capacity include coma, minors (except exempt), and patients with inadequate psychiatric illness or poisoning.
- Medical emergency
- In a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been previously prepared (such as advance instructions)
- Research, audit, and evaluation
- Individuals involved in medical research, financial or management audits, or program evaluations have access to medical records. They are not allowed access to any identifying information.
- The risk of death or danger
- Information in the records may be shared with an unauthorized authority when failure to do so will result in death or harm either to the patient or to others. Information can not be used, however, to initiate or strengthen the allegations unless the previous criteria are met (ie, information from drug testing can not be used to bring allegations of ownership to the patient). This rule is set out in the case of United States Supreme Court Jaffe v. Redmond [1].
Canada
In 1992 the decision of the Supreme Court of Canada at McInerney v. MacDonald gives patients the right to copy and check all information in their medical records, while the records themselves remain the property of health care providers. The Personal Health Protection Act (PHIPA) 2004 contains regulatory guidelines to protect the confidentiality of patient information for health care organizations that act as administrators of their medical records. Despite legal precedents for national access, there are still some differences in the laws depending on the province. There is also some confusion among providers about the range of patient information they should give access, but the language in the highest court ruling gives patients access to all their records.
United Kingdom
In the United Kingdom, the Data Protection Act and then the Freedom of Information Act 2000 provide patients or their representatives the right to a copy of their records, unless information violates confidentiality (for example, information from other family members or where the patient has requested for information not may be disclosed to a third party) or will be harmful to the patient's health (eg, some psychiatric assessments). Additionally, the law gives patients the right to check for any errors in their records and insists that amendments are made where necessary.
Destruction
In general, entities with medical records must keep the records for a certain period. In the UK, medical records are required for the patient's lifetime and legally as long as the action of the complaint can be filed. Generally in the UK, recorded information should be kept legally for 7 years, but for medical records additional time should be allowed for each child to reach the age of responsibility (20 years). Medical records are required years after the death of a patient to investigate a disease within a community (eg, industrial or environmental disease or even death at the hands of the murdering physician, as in the case of Harold Shipman).
Breach
Outsourcing of transcription and storage of medical records has the potential to violate patient-physician confidentiality by possibly allowing irresponsible persons access to patient data. The falsification of medical records by a medical professional is a crime in most jurisdictions of the United States. Governments often refuse to disclose medical records of military personnel who have been used as experimental subjects.
Data violations
In view of a series of medical data breaches and lack of public trust, some countries have enacted laws that require safeguards to be applied to protect the security and confidentiality of medical information because it is shared electronically and gives patients some important rights to monitor medical records and receive notices for loss and acquisition of information unauthorized health. The United States and the European Union have enacted a breach of mandatory medical data violations.
Patient medical information can be shared by a number of people both in the health care industry and beyond. The Health Insurance Portability and Accessibility Act (HIPAA) is a United States federal law relating to medical privacy in force in 2003. This law sets standards for patient privacy in all 50 states, including the patient's right to access the records themselves.. HIPAA provides protection, but does not solve problems that involve medical records privacy.
Medical providers and health care experience 767 security breaches resulting in confidential health information being hacked from 23,625,933 patients during the period 2006-2012.
Privacy
The Federal Health Insurance Portability and Accessibility Act (HIPAA) addresses privacy issues by providing guidelines for the handling of medical information. Not only is it bound by its professional Code of Ethics (in the case of doctors and nurses), but also by laws on data protection and criminal law. Professional secrecy applies to practitioners, psychologists, nurses, physiotherapists, occupational therapists, nursing assistants, chiropodists, cello players and administrative personnel, as well as additional hospital staff. Maintaining the confidentiality and privacy of patients implies first in medical history, which must be adequately maintained, remains accessible only to authorized personnel. However, privacy rules should be considered in all areas of hospital life: privacy during anamnesis and physical exploration, privacy at the time of information to relatives, conversations between health care providers in the corridor, maintenance of adequate patient data collection in hospital nursing control (board , whiteboard), telephone conversation, open intercom...
See also
- Bioethics
- Electronic health records
- Hospital information system
- Medical history
- Medical law
- OpenNotes
- Right to know
- Physical check
- Doctor-patient privileges
- Midwife
- Maintenance
- Pharmacy
References
External links
- Personal Medical Note from MedlinePlus
- The American Association of Health Information Management
- Medical Record of Privacy - Electronic Privacy Information Center (EPIC)
Organizations that deal with medical records
- ASTM Continuity of Care Record - an XML healthcare summary standard, CCR can be created, read and interpreted by various EHR systems or Electronic Medical Records (EMR), allowing easy interoperability between different entities.
- The American Association of Health Information Management
Source of the article : Wikipedia
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