Medical record

A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care [1][2]. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal. Although medical records are traditionally compiled and stored by health care providers, personal health records maintained by individual patients have become more popular in recent years.

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Purpose

The information contained in the medical record allows health care providers to provide continuity of care to individual patients. The medical record also serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care, assisting in protecting the legal interest of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient. In addition, the medical record 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. 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. [3].

Format

Traditionally, medicals records have been written on paper and kept in folders. These folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues. Active records are usually housed at the clinical site, but older records (eg those of the deceased) are often kept in separate facilities.

The advent of electronic medical records has changed not only the format of medical records, but has increased accessibility of files.

Contents

Although the specific content of the medical record may vary depending upon specialty and location, it usually contains the patient's identification information; the patient's health history (what the patient tells the health care providers about his or her past and present health status); and the patient's medical examination findings (what the health care providers observe when the patient is examined). Other information may include lab test results; medications prescribed; referrals ordered to health care providers; educational materials provided; and what plans there are for further care, including patient instruction for self-care and return visits[4]. In some places, billing information is considered to be part of the medical record [5].

Demographics

Demographics include information regarding the patient which 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 occupational information. 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.

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). 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 (ie occupational exposure to asbestos).

Habits

Various habits which impact health, such as tobacco use, alcohol intake, recreational drug use, 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 preferences.

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 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 (ie 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 that the patient is experiencing which 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 and examination of the different organ systems, especially ones which might directly be responsible for the symptoms that 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

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, 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 (eg complete blood count) radiology examinations (eg X-rays), pathology (eg biopsy results), or specialized testing (eg 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.

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 rule governing production, ownership, accessibility, and destruction.

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

Ownership

In the United States, the data contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record. Therefore, patients have the right to ensure that the information contained in their record is accurate. Patients can petition their health care provider to remedy factually incorrect information in their records.

In the United Kingdom, the NHS's medical records belong to the Department of Health.

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 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 drafted previously (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 (ie, 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 well-being (eg 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 of time. In the United Kingdom, medical records are required for the lifetime of a patient and legally for as long as the time 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 of doctors committing murders, e.g. Harold Shipman). ^[7]

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.

See also

• Medical history
• Physical examination
• Electronic medical record
• Electronic health record
• Physician-patient privilege

References

• ^  UK newspaper article "Government 'Breached Ex-Soldier's Human Rights'" Guardian. October 20th, 2004.

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