Medical records are physical collections of patient-related materials that include written notes and materials, graphs, test results, x rays, and other data.
Medical records have different purposes for the health care practitioner and the patient. The practitioner maintains records to document individual contacts with the patient, to monitor the individual patient's health status, to comply with legal requirements, and to monitor the practitioner's own professional behaviors.
The patient uses his or her medical record to provide information to various health care providers and to maintain a knowledge of his or her own health care.
Medical records are created and maintained by health care professionals to supply medical practitioners with a sequential history of a patient's medical care and conditions affecting it. An individual's medical record is the collection of information that pertains solely to that person. It contains the information health care practitioners need to evaluate and treat the patient's health care needs. The record provides the patient's history of health care, past illnesses, test results, and other specific data.
Individual medical records are confidential, except in cases where disclosure of its contents are required by law. Information contained in a patient's medical record cannot be released without the patient's written consent.
Apprenticeship—Training a person who is new to the particular work being done, can also be onthe-job training.
Confidential—In medicine, implies a mutual trust between the patient and health care practitioner.
Medical history—Information about the patient's past medical services, procedures, illnesses, and needs.
Practitioner—Someone who engages in the science of medicine.
Social history—Information about the patient's past social needs and services utilized.
Medical records are created by health care professionals and are an aid in the care of their patients. Specific information regarding a patient is contained in the records. Contents of medical records include health care professionals' notes about the patient, medical and social histories, physicians' assessments, x ray reports, the results of tests, and other materials specific to the treatment of the patient. Materials may be provided to other health care professionals or hospitals only with the patient's written consent.
Medical records are maintained by physicians, physician assistants, nurses, and medical records clerks. Only authorized personnel can make entries in the record.
Health care team roles
Health care professionals are required to keep accurate records. Information is recorded every time the patient is seen by a health care practitioner. Findings of each practitioner who treats the patient records are recorded in the appropriate section of the record.
Health care practitioners receive training in keeping accurate medical records in several different ways, including:
- training during medical or nursing school
- classes at a vocational or business school• apprenticeship or on-the-job training
Clayton, Paul D. M.D. For the Record: Protecting Electronic Health Information. Washington, DC: National Academy Press, 2000.
Applebaum, Paul S., M.D. "Threats to the Confidentiality of Medical Records-No Place to Hide." Journal of the AMA 283, no. 6 (February 9, 2000).
U.S. House of Representatives Committee on Commerce. Washington, DC (202) 225-5735. <http://comnotes.house.gov>.
Peggy Elaine Browning