MEDICAL RECORD

    Medical records are used to keep track of activities and transactions that take place between patients and health care providers. They provide diagnostic information, procedures, laboratory testing, and other services. Medical records enable us to track and analyze trends in health-care utilization, patient characteristics, and care quality.

There are three types of medical records commonly used by patients and doctors:

• Personal health record (PHR)
• Electronic medical record (EMR)
• Electronic health record (EHR)

Medical records are usually precise and complete because they come from health care practitioners. The data is automatically collected, including information that patients may not think to add or feel comfortable revealing through traditional data sources such as surveys. However, because the material is written in a specific context, it can be misconstrued if taken out of context. 

The content of Patient Records

• Identification Sheet- The information on the identity sheet is obtained upon registration or admittance. It includes the patient's name, address, phone number, insurance carrier, and policy number, as well as the patient's diagnoses and discharge disposition.

• Problem lists- It details the patient's main illnesses and surgeries.

• Medication record- It contains a list of medications that have been prescribed for and then administered to the patient.

• History and physical- It describes the patient's main illnesses and procedures, as well as any relevant family history of diseases, patient health habits, and current medications.

• Progress notes- It should include the patient's response to treatment as well as the provider's observations and treatment plans for the future.

• Consultations- It keeps track of opinions regarding the patient's condition expressed by health care providers other than the attending physician.

• Physician’s orders- It contains doctor's orders, instructions, and prescriptions given to other members of the healthcare team.

• Imaging and X-ray reports- Interpreting X-ray, mammography, ultrasound, scan, and other imaging results.

• Laboratory reports- They contain the findings of testing on bodily fluids, cells, and tissues. Hematology and Urinalysis are included.

• Consent and authorization forms- Are admission, treatment, surgery, and information release consents.

• Operative report- It describes any surgeries conducted and names the surgeons and assistance.

• Pathology report- It defines tissue removed following any surgical procedure as well as the diagnosis based on that tissue's evaluation.

• Discharge summary- It covers the hospital stay, including the reason for admission, noteworthy results from tests, procedures performed, therapies administered, responses to treatments, condition at discharge, and medication, activity, diet, and follow-up care instructions.

Some Examples of the parts of Medical Records:

 

References:

https://www.nlm.nih.gov/nichsr/stats_tutorial/section3/mod2_medical.html#:~:text=Medical%20records%20are%20used%20to,characteristics%2C%20and%20quality%20of%20care 

https://www.amihm.org/purposes-of-patient-records/