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. ... In semantics, the patient is the passive part of a process. ... Medical history can either refer to the History of medicine personal (case) medical history: anamnesis medical history of a family: Family history (medicine) This is a disambiguation page — a navigational aid which lists pages that might otherwise share the same title. ... 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 and allied health professions [1]. The healthcare industry is one of the worlds largest and fastest-growing industries, consuming over 10... 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. ... This article needs to be cleaned up to conform to a higher standard of quality. ...

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]. Medical school generally refers to a tertiary educational institution (or part of such an institution) which is involved in the education of future medical practitioners (medical doctors). ... 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... In engineering and manufacturing, quality control and quality engineering are involved in developing systems to ensure products or services are designed and produced to meet or exceed customer requirements and expectations. ... This article needs to be cleaned up to conform to a higher standard of quality. ...

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. It has been suggested that this article or section be merged with Electronic Health Record. ...

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. A demographic or demographic profile is a term used in marketing and broadcasting, to describe a demographic grouping or a market segment. ...

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. Medical history can either refer to the History of medicine personal (case) medical history: anamnesis medical history of a family: Family history (medicine) This is a disambiguation page — a navigational aid which lists pages that might otherwise share the same title. ... 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 to be cleaned up to conform to a higher standard of quality. ... 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 typical modern surgery operation For other meanings of the word, see Surgery (disambiguation) Surgery (from the Greek cheirourgia meaning hand work) is the medical specialty that treats diseases or injuries by operative manual and instrumental treatment. ... A report is a type of document written by someone or a group of people. ... A typical modern surgery operation For other meanings of the word, see Surgery (disambiguation) Surgery (from the Greek cheirourgia meaning hand work) is the medical specialty that treats diseases or injuries by operative manual and instrumental treatment. ... Obstetrics (from the Latin obstare, to stand by) is the surgical specialty dealing with the care of a woman and her offspring during pregnancy, childbirth and the puerperium (the period shortly after birth). ... A pregnant woman Pregnancy is the carrying of one or more embryos or foeti by female mammals, including humans, inside their bodies. ... A family of Ouagadougou, Burkina Faso in 1997 A family is a domestic group of people, or a number of domestic groups, typically affiliated by birth or marriage, or by comparable legal relationships including domestic partnership, adoption, surname and in some cases ownership (as was the case in the Roman... Example pedigree chart A pedigree chart is a chart which tells you all of the known phenotypes for an organism and its ancestors, most commonly humans, show dogs, and race horses. ... See: relational model personal relationship mathematical relationship, including: inverse relationship direct relationship relation (mathematics). ... ... Species N. glauca N. longiflora N. rustica N. sylvestris N. tabacum Ref: ITIS 30562 as of August 26, 2005 Tobacco (, L.) refers to a genus of broad-leafed plants of the nightshade family indigenous to North and South America or to the dried and cured leaves. ... In general usage, alcohol (from Arabic al-ghawl الغول) refers almost always to ethanol, also known as grain alcohol, and often to any beverage that contains ethanol (see alcoholic beverage). ... Recreational drug use is the use of psychoactive drugs for recreational rather than medical or spiritual purposes, although the distinction is not always clear. ... Marines doing push-ups. ... In nutrition, the diet is the sum of the food consumed by an organism. ... Sexual orientation, sexual preference or sexual inclination describes the focus of a persons amorous or erotic desires, fantasies, and feelings. ... Vaccination is a term coined by Edward Jenner for the process of administering live, albeit weakened, microbes to patients, with the intent of conferring immunity against a targeted form of a related disease agent. ... The immune system is the system of specialised cells and organs that protect an organism from outside biological influences. ...

Medical encounters

Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practicioner, 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 entirity 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 is short for subjective, objective, assessment, and plan. ...

• 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.).

In medicine, 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, 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 is short for subjective, objective, assessment, and plan. ... 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. A complete blood count (CBC) or full blood count (FBC) is a test requested by a doctor or other medical professional that gives information about the cells in a patients blood. ... Chest X-ray Radiology traditionally was the branch of medical science dealing with the medical use of X-rays emitted by X-ray machines or other such radiation devices for the purpose of obtaining visual information as part of medical imaging. ... 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 (in ancient Greek pathos = feeling, pain, suffering and logos = discourse or treatise, i. ... 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 their set of illnesses/treatments. Intensive care medicine or critical care medicine is concerned with providing greater than ordinary medical care and observation to people in a critical or unstable condition. ... 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 any actions. ... 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. In recent years, the terms electronic signature and digital signature have come into widespread, and somewhat confused, use. ...

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 HIPAA guidelines. 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 their 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. Capacity and incapacity are legal terms that refer to the ability of persons to make certain binding dispositions of their rights, such as 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. ... This article is in need of attention from an expert on the subject. ... Emancipation — Oh, Edwin dear! Heres Tom Jones. ... Psychiatry is the branch of medicine that studies, diagnoses and treats mental illness and behavioral disorders. ... ... 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, 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 1984 is a British Act of Parliament that provides a legal basis for the privacy and protection of data of UK citizens and businesses. ... The Freedom of Information Act 2000 (2000 c. ...

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] Dr. Harold Shipman Dr Harold Frederick Shipman, known as Fred Shipman to his family (January 14, 1946 – January 13, 2004) was a British general practitioner who was the most prolific known serial killer in British history (and possibly the world). ...

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.
• Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.

Outsourcing (or contracting out) is often defined as the delegation of non-core operations or jobs from internal production within a business to an external entity (such as a subcontractor) that specializes in that operation. ...

See also

• Medical history
• Physical examination
• Electronic medical record
• Electronic Health Record
• Physician-patient privilege

Medical history can either refer to the History of medicine personal (case) medical history: anamnesis medical history of a family: Family history (medicine) This is a disambiguation page — a navigational aid which lists pages that might otherwise share the same title. ... In medicine, physical examination, or clinical examination, is the process by which the physician investigates the body of a patient for signs of disease . ... It has been suggested that this article or section be merged with Electronic Health Record. ... An Electronic Health Record (EHR) is a medical record or any other information relating to the past, present or future physical and mental health, or condition of a patient which resides in computers which capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary purpose of providing... 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

• Personal Medical Records from MedlinePlus
• American Health Information Management Association
  • Definition of the Health Record for Legal Purposes
• Medical Record Privacy - Electronic Privacy Information Center (EPIC)
• The OB Medical Record - Obstetrics/Gynecology Medical Student Clerkship Syllabus, University of Nevada, Reno School of Medicine

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. ... Obstetrics (from the Latin obstare, to stand by) is the surgical specialty dealing with the care of a woman and her offspring during pregnancy, childbirth and the puerperium (the period shortly after birth). ... The shamefulness associated with the examination of female genitalia has long inhibited the science of gynaecology. ... The University of Nevada, Reno (UNR or Nevada) is a university that is located in Reno, Nevada and is known for its programs in agricultural research, animal biotechnology, and mining-related natural sciences. ...

Organizations dealing with medical records

• ASTM Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or Electronic Medical Record (EMR) systems, allowing easy interoperability between otherwise desperate entities.
• American Health Information Management Association