Medical record
[1] A medical record includes a variety of types of "notes" entered over time by healthcare 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 requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.
An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
[11][12] For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized[13] forms to ensure patients' privacy is maintained.
The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient.
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc.
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.
Medical records are legal documents that can be used as evidence via a subpoena duces tecum,[20] and are thus subject to the laws of the country/state in which they are produced.
While many hospitals and doctor's offices have since done this successfully, electronic health vendors' proprietary systems are sometimes incompatible.
In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper.
In that ruling, an appeal by a physician, Dr. Elizabeth McInerney, challenging a patient's access to their own medical record was denied.
The patient, Margaret MacDonald, won a court order granting her full access to her own medical record.
[31] The case was complicated by the fact that the records were in electronic form and contained information supplied by other providers.
This documentation must happen in a timely manner and encompass each and every form of treatment the patient receives, as well as other necessary information, such as the patient's case history, diagnoses, findings, treatment results, therapies and their effects, surgical interventions and their effects, as well as informed consents.
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).
A 2018 study found discrepancies in how major hospitals handle record requests, with forms displaying limited information relative to phone conversations.
Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.
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.
[39] 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.
The Health Insurance Portability and Accessibility Act (HIPAA) is a United States federal law pertaining to medical privacy that went into effect in 2003.
[44] The federal Health Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy by providing medical information handling guidelines.
[45] Not only is it bound by the Code of Ethics of its profession (in the case of doctors and nurses), but also by the legislation on data protection and criminal law.
The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel.
