An important form of documents that follow us our entire lives are 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 documentations of patients’ 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, that were 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.
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 being maintained within the healthcare system.
The purpose of these records are to make sure patients receive great quality of care, as it provides all healthcare providers an insight into everything about you. From your medical history to social information, they get a better picture as to 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.
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.
Paper records are paper-based and kept in folders, that 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 kept together, medications, respiratory, lab, 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 labelled 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 contain some electronically stored information, and some paper-based. Paper documents can be switched to electronic, which takes some time, thus it is hybrid.
Explain 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 the 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
A 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:
- 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 including 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 the case they cannot communicate their medical care. These include the DNR, known as ‘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:
- 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 comes 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 responsible party
- Occupation, employer phone number and employer of the responsible party
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.
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.
This section contains qualitative documentation of the current condition of the patient. This includes the onset, complaints, severity, quality, and chronology.
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.
This section includes a summarization of all the primary diagnosis and salient points.
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 A 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
- 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.