Medical records provide health information about a patient. Nitin Chhoda discusses the value of having a complete and accurate information of a patient’s health records so that practitioners can decide the best treatment for a patient’s health.
A medical record, which can also be entered in a physical therapy documentation process, will also include information about allergies as well as details about each visit to the healthcare provider’s clinic.
Like all legal documents, medical records are kept according to laws that usually relate to certification or licensing of a medical professional or medical clinic.
Maintenance of medical records is required by state or federal laws, depending on the specific requirements, and for good reason. Incorrectly maintained medical records could cause serious harm to the patient.
A doctor who neglects to record allergies to medications could be held responsible if a patient is administered that medication in the future because the information is not included in the patient’s medical record.
Medical and Health Records
Medical records can be the folder where all medical information for a single patient is stored as well as the cumulative history that a medical record provides.
A health record is the critical information about a patient contained in a medical record that is sent from one medical provider’s clinic to another.
Medical records can include charts, x-rays, prescription orders for physical therapies or medications, observations, test results, and the date of each previous visit to the medical clinic.
Any important type of note about the patient will also be included, such as pre and post operative notes and operative notes, admission notes, SOAP or progress notes, discharge notes, delivery and postpartum notes, and on-service notes.
Medical Records and More
A medical record can also be useful for future clinicians who may not have the opportunity or the context to know to ask certain questions about the patient’s medical history.
Until fairly recently, medical records laws were kept and maintained by health professionals only, and patients had little to no access to their own medical record.
However, today patient’s have more rights and can not only view their own medical record but have the opportunity to comment on some entries that they feel are inaccurate.
The other way that has helped medical care to improve is the use of medical records as educational materials. Medical school students and resident physicians can get the next best thing to first hand experience if they can compare a real medical record, which would be anonymous, to a current problem they are trying to diagnose or treat.
A Form of Communication
Besides being a compilation of all medical information relating to a patient, a medical record is also a form of communication and a way to share knowledge.
Because medical records can be so important and so helpful, there are legal precedents for maintaining medical records correctly. Medical services providers are also required to keep medical records for seven years after the last recorded addition to the record.