Medical record

For the New York journal published by the Washington Institute of Medicine, see Medical Record (journal).

For the BBC Radio 4 medical programme, see Case Notes (radio show).

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.^[1]. The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a fundamental requirement of health care providers and is generally enforced as a licensing or certification prerequisite.

The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.

Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites^[2]. This concept is supported by US national health administration entities^[3] and by AHIMA, the American Health Information Management Association.^[4]

A medical record folder being pulled from the records

Because many consider information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal^[5]. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request. ^[6].

Purpose

The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.

The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.

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.[5].

Auxiliary purpose

In addition, the individual medical record anonymised 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.

Contents

A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient^[7]. Further information varies with the individual medical history of the patient.

The contents are written by medical providers, and patients until relatively recently had no say in what was contained in it. Recent advances in health care records privacy and access rules have generally provided for a patient's right to review and have recorded in the medical record objections to the accuracy of certain entries.

Media applied

Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.

The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research.

Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.

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.

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)^[8]. 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 (e.g. occupational exposure to asbestos).

Habits

Various habits which impact health, such as tobacco use, alcohol intake, 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 orientation.

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 and 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.

Medical encounters

Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety 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:

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 the patient is experiencing that 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 , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms 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.).

Orders and Prescriptions

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, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health.

Test results

The results of testing, such as blood tests (e.g., complete blood count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., 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.

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 his or her set of illnesses/treatments.

There are several types of information needed to be recorded while tracing the state of a patient's daily health:
1. Vital Signs: Body Temperature, Pulse Rate(Heart Rate), Blood Pressure and Respiratory Rate.
2. Intake: Medication, Fluid, Nutrition, Water and Blood, etc.
3. Output: Blood, Urine, Excrement, Vomitus and Sweat, etc.
4. Observation of Pupil size.
5. Capability of four limbs of body

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 rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself.

Demographics

Demographics include patient information that 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 occupation. It may also contain information regarding the patient's health insurance. It is common to also find emergency contacts located in this section of the medical chart.

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 out with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature.

Informational self-determination

The informational self-determination is a basic human right. Hence a patient's record should belong to the patient, but it seldom happens so.

Ownership for patient's record

Ownership and keeping of patient's records varies from country to country.

US law and customs

In the United States, the data contained within the medical record belongs to the patient^{[citation needed]}, whereas the physical form the data takes belongs to the entity responsible for maintaining the record per the Health Insurance Portability and Accountability Act^[9]. Therefore, patients have the right to ensure that the information contained in their record is accurate^{[citation needed]}. Patients can petition their health care provider to remedy factually incorrect information in their records.^{[citation needed]}

UK law and customs

In the United Kingdom, ownership of the NHS's medical records belong to the Department of Health,^[10] and this is taken by some to mean copyright also belongs to the authorities.^[11]

German law and customs

In Germany ownership of patient's records is not explicitly codified. Hence traditional keeping of patient's records is with the hospitals and the practitioners. There is no comprehensive data set containing all information on one patient in one file defined yet. Since 1995, patients are identified via a health insurance card that includes name and address information as well as an ID assigned by the insurance provider. An upgrade to advanced health insurance cards (Elektronische Gesundheitskarte) that can store additional medical information was planned for 2006. Discussion on the benefit, the associated cost, and on data privacy issues is still ongoing as of 2011.

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 the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.

Capacity

When a patient does not have capacity (is not legally able) to make decisions regarding his or her 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 previously drafted (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 (i.e., 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 wellbeing (e.g., 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.

Destruction

In general, entities in possession of medical records are required to maintain those records for a given period. In the United Kingdom, medical records are required for the lifetime of a patient and legally for as long as 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 deaths at the hands of doctors committing murders, as in the Harold Shipman case).^[12]

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.
• Falsification of a medical record by a medical professional is a felony in most United States jurisdictions.
• Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.

Standardization

See also

Medicine portal

• Medical history
• Medical law
• Electronic medical record
• Electronic health record
• Hospital information system
• Physical examination
• Physician-patient privilege
• Online office suite

References

1. ^ [1]
2. ^ [2]
3. ^ National Institute for Health
4. ^ American Health Information Management Association
5. ^ Health Information Privacy
6. ^ [3]
7. ^ A Sample Health Record
8. ^ [4]
9. ^ http://aspe.hhs.gov/admnsimp/pl104191.htm
10. ^ Moyle R (30 November 1976). "Written Answers (Commons): SOCIAL SERVICES: Medical Records (Ownership and Storage)". Hansard 921 (c91W). http://hansard.millbanksystems.com/written_answers/1976/nov/30/medical-records-ownership-and-storage. "Personal medical records, including X-rays, in respect of patients treated under the NHS are held to be the property of the Secretary of State. NHS hospital medical records are stored in premises designated by the appropriate health authority. Access to a patient's medical records is governed in the patient's interest by the ethics of the medical and allied professions." 
11. ^ "Policy and Procedure For Records: Retention & Disposal" (PDF). Mersey Care NHS Trust. December 2003. http://www.merseycare.nhs.uk/Library/About_Mersey_Care/Policies_Procedures/IT_Policies/Retenion%20and%20%20Disposal.pdf. Retrieved 2008-07-05. "ownership and copyright in these records as a rule is with the NHS Trust or Health Authority, not with any individual employee or contractor." 
12. ^ "Government 'Breached Ex-Soldier's Human Rights'". The Guardian. October 20, 2004. http://www.guardian.co.uk/military/story/0,11816,1331784,00.html. 

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 ICMCC portal on access to electronic medical records. The portal includes a blog to share and discuss experiences for both patients and clinicians as well as an extended overview of relevant literature.

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 disparate entities.
• American Health Information Management Association