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The 10 Components Of a Medical Record In A Hospital

Posted in Electronic Health Records

Last Updated | December 1, 2022

Table of Contents

Executive Summary – 10 Components of  a Medical Record

We all have medical records, therefore it’s important to familiarize yourself with what exactly is contained in them as well as your legal rights in relation to this vital information. Most of a patient’s medical records are based on the level of care they need, therefore the topic we will cover today is about 10 components of medical records in detail and more.

Overview – 10 Components of  a Medical Record

An important form of document that follows us our entire lives is medical records. They are both legal and medical documents that come with specific rights and stipulations to help prevent the info from being shared unlawfully or falling into the wrong hands.

The US Department of Health and Human Services states that these documents are highly sensitive, meaning they can only be accessed by the individual in question or their representative. With that being said, let’s look at medical records and their components in detail.

What Are Medical Records In A Hospital?

Medical records found in hospitals are systematic documentation of patient’s medical care and history. They contain a patient’s health information (which is also referred to as PHI) that includes health history, billing information, identification information, and findings of medical examinations.

Medical Record Documentation Examples Using Electronic Health Records?

Traditionally, medical records were documented in paper form, which was separated into sections using tabs. However, printed reports started generating, and they would be added to the right tabs. Then, since the development of the electronic health record (EHR), these sections are now found within the electronic records in separate menus.

An EHR digitally records a patient’s health information. It includes informationally typically found in paper charts as well as vital signs, diagnoses, medical history, immunization dates, progress notes, lab data, imaging reports, and allergies. Other information such as demographics and insurance information may also be contained within these records.

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What Do Medical Records Contain?

Medical records usually contain information regarding patients’ medical history and health. The amount and type of information, as well as the level of detail, found in a person’s medical record, may differ depending on the patient. Medical documentation of a person is determined by the amount of care required by them.

What Is The Purpose Of The Medical Record?

Every time someone visits any kind of healthcare provider, a record is created. This means almost every single person in the U.S. has a medical record maintained within the healthcare system.

The purpose of these records is to make sure patients receive the great quality care, as it provides all healthcare providers insight into everything about you. From your medical history to social information, they get a better picture of what the best route of treatment is for the patient.

A medical record helps collect all your data in one place to ensure all your doctors across different hospitals have the right information. It helps healthcare providers keep a track of everything you have been through- which allows them to help you better.

Medical records also help for administrative and financial purposes, so medical record providers can document their work. Plus, it makes it easier for doctors and nurses to compile all the data and analyze it.

You can hire the best vendor for Clinical Data Management System and make record-keeping easier for yourself.

What Is The Importance Of Medical Records In Healthcare?

There are four main reasons medical records are important in healthcare.

Reduces Risk Of Malpractice

Documenting all information helps mitigate the risk of malpractice. A record that has been well-maintained will be able to reduce liability concerns if a claim is made.

Helps To Maintain Communication Amongst Healthcare Personnel

Proper documents help to communicate the quality of care providers delivered to patients and helps them easily continue their care all their life.

Ensure You Get Reimbursed

A medical record that has been appropriately documented can help in facilitating an effective revenue process, reduce the hassles of claims processing, get you reimbursements and expedite payment.

Records PQRS Measures and Hospital Quality

The government has increasingly been asking hospitals to provide value-based purchasing metrics that documentation allows. These include Hospital Quality Indicators and PQRS measures.

What Do Medical Records Look Like?

Medical records can be found in three primary formats: electronic, paper, and hybrid.

Electronic Medical Records

An electronic record is like a paper one, except all the information gets stored electronically. Because order entry is computerized, physicians’ orders can easily be placed using a computer, making sure there is less of a chance handwriting may be misinterpreted or illegible.

Many EHR systems also have tools for clinical decision support, so physicians can reference literature and look up different conditions to help treat patients.

In addition to the EHR systems, hospitals can get other healthcare software solutions to have better access to patient information. Folio3 can help design such software solutions with customized features according to the hospital’s needs.

Paper

Paper records are paper-based and kept in folders, that are then kept filed into a larger filing system. They can take up too much physical space, and are easier to lose or misfile. There are two ways to organize these:

Source-Oriented Medical Records

Source-oriented records are those that are grouped together based on point of origin. The physician’s notes are filed together, the nursing records are kept together, and medications, respiratory, lab, and physical therapy are kept together as well.

Problem-Oriented Medical Records

Problem-oriented medical records (POMR) are those that focus on the patient. The physician first creates a list of problems, numbered. Then, progress notes are used to document the patient’s treatment and how they are responding to it.

Each note is then labeled according to the number of the problem it is meant to address. This form of indexing is to allow clinicians an easy way to take the courses of treatment for the patient.

Hybrid Records

Hybrid records contain some electronically stored information and some paper-based. Paper documents can be switched to electronic, which takes some time, thus it is a hybrid.

At this point, it’s evident that there are various types of medical records in the healthcare industry, but how do you comply with the various regulations? It’s best to acquire and install healthcare compliance solutions, so your healthcare organization can manage multiple types of records while abiding by the regulations. Keep in mind that compliance is important to keep operating the healthcare organization.

Explain the Components Of Medical Records

The components of a medical record are meant to help both current and future health professionals better understand the wellness and health of the patient, along with all other information to improve patient care.

There are ten main components, which we will be exploring in detail.

What Are The 10 Components Of A Medical Record?

Here are the ten components of a medical record, along with their descriptions:

1.   Identification Information

One of the first important components you can find in medical records is identification information. Medical records need to have information to help identify who the history belongs to. For example, your date of birth, name, marital status, and social security number may be noted down.

2.   Medical History

Medical history is considered for everyone, even those who have never been to a doctor or hospital. However, most people in the U.S. do have at least some form of medical history, whether large or small. The history can include:

  • Allergies
  • Treatments
  • Medical Care
  • Present and past diagnosis

Even if someone does not have a medical history is added to the record. It helps doctors understand whether their illness is chronic or acute, seasonal or situational.

3.   Medication Information

Medicines a patient is ingesting need to be documented in their medical record as it could affect their course of treatment. Whether they have tried herbal remedies, illegal substances, or OTC medication, everything should be included.

This information may be gathered through patient testimony or through prescriptions from past doctors already on file.

4.   Family History

A patient’s family’s medical history can play an important role in their health. Many health concerns can be genetic, making them important to add to the file. Some health problems of family members may not be worrisome, however, some hereditary diseases and cancers that may be passed down should be documented.

Thus, if it is accessible, a patient’s family’s medical history is often added to their medical record.

5.   Treatment History

A person’s treatment history is another vital part of the patient’s medical record. The treatment history encompasses all treatments they have ever undergone and their results. Some things include:

  • Chief complaints
  • History of illness
  • Vital signs
  • Physical examination
  • Surgical history
  • Obstetric history
  • Medical allergies
  • Family history
  • Immunization history
  • Habits include diet, alcohol intake, exercise, drug use/abuse, smoking, etc.
  • Developmental history

6.   Medical Directives

Medical directives are crucial documents to outline directions by the patient regarding what they want or do not want in case they cannot communicate their medical care. These include the DNR, known as the ‘do not resuscitate order, and their will.

7.   Lab results

Different lab results that the patient has received are all added to the record. These can be results on lab results related to cells, tissues, or body fluids. Other reports such as X-Ray and imaging tests produced through mammograms, scans, x-rays, and ultrasounds are all added as well.

8.   Consent Forms

Patients should be able to make informed decisions about their care; thus the physician should let the patient know all important information about all medical procedures. Information includes:

  • Diagnosis
  • Recovery chances
  • Recommended treatment
  • Benefits and risks of the treatment
  • Risks if the treatment is not taken
  • Success probability if treatment is taken
  • Length of recovery time and challenges

9.   Progress Notes

Progress notes are made by physicians if changes or new information come up during the course of the treatment. Some information included within these notes are:

  • Bowel and bladder functions
  • Observation of the mental and physical condition of the patient
  • Sudden changes taking place
  • Food intake
  • Vital signs

10.   Financial Information

Financial information is also an important part of a patient’s medical records. Some of the information included is:

  • Subscriber name
  • Policy number
  • Name, phone number, and address of insurance payer
  • Relationship of the patient to the one insured
  • Phone number, address, and name of the responsible party
  • Occupation, employer phone number, and employer of the responsible party

While understanding the components of medical records is important, compiling all this information at a central place can be challenging. For this purpose, hiring healthcare app development services is suitable as they can design the apps or software that gather, organize, and sync the data, eliminating the need for manual work.

Conclusion – 10 Components of  a Medical Record

Medical records are an integral part of the healthcare system and are meant to make the quality of care better. The components within these records are all carefully selected to give a robust view of everything relating to patient care to all healthcare personnel.

Looking for top EHR recommendations for therapists? Here you go!

FAQs – 10 Components of  a Medical Record

How To Properly Document Medical Records?

Every entry should have the time, date, and sign on it. The person making any entries should write their role and name. Make sure to document everything as quickly as possible. Abbreviations should only be used if they are approved. Addendums made should be communicated to all nursing staff and teams.

If any mistake has been made, a single strike should be made through the entry. Once it is corrected, it should be signed and dated. The SOAP method, which stands for: Subjective, Objective, Assessment, and Plan, is what is used for effective documentation by medical staff.

Subjective

This section contains qualitative documentation of the current condition of the patient. This includes the onset, complaints, severity, quality, and chronology.

Objective

This section is where physicians document measurable, repeatable, and objective facts regarding the status of the patient. This includes objective observations, physical exam findings, and lab results.

Assessment

This section includes a summarization of all the primary diagnoses and salient points.

Plan

This section is to document a clear-cut plan which includes referrals, new medications, procedures, and further investigations that will be charted.

List The 9 Contents Of The Patient’s Medical Record

  • Identification Information
  • Medical History
  • Medication Information
  • Family History
  • Treatment History
  • Medical Directives
  • Lab results
  • Consent Forms
  • Progress Notes

List The Components Of Problem-Oriented Medical Records

There are four components of the problem-oriented medical record form:

  • Data regarding the patient’s exams, mental status, history, etc.
  • The problems the patient is facing
  • A treatment plan based on each problem
  • Progress notes according to each problem and the response of the patient to each course of treatment

 Can a properly designed UX design in healthcare promise better record-keeping?

Recently, the use of technology has put doctors behind the computer screen rather than in front of the patient, but it’s because of a bad design. For this reason, a proper UX design in healthcare systems, interface design, information design, and artificial intelligence will help enhance record-keeping and allow doctors to connect with patients.

Which is the best telemedicine software company?

While there are many companies out there, Folio3 remains one of the best telemedicine software companies. That’s because they design the software according to the hospital’s needs and can customize the software to meet the growing needs of the hospitals.

Is HL7 integration suitable for healthcare apps?

HL7 is basically a set of instructions and standards that focuses on information and data transfer between various healthcare providers. So, HL7 integration in healthcare apps is an excellent way of ensuring standard information transmission and compliance with regulations.

Are healthcare apps important for hospitals?

They are not mandatory, but healthcare application integration with traditional hospital systems can improve healthcare services. In addition, it can make hospital operations more efficient with on-time notifications.

Is UX in healthcare responsible for better healthcare provision?

A well-designed UX in healthcare software solutions will meet the needs of different stakeholders in the hospital. In addition, it helps maintain healthcare standards, so the answer is yes!

 

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