Importance of a Medical Record for Documentation
The terms health record, medical document, and patient medical records are often used interchangeably to refer to the detailed documentation of a patient’s care overtime at one particular medical facility in one region.
But while many are familiar with these terms, few are aware of the distinction between them. While they all refer to a medical document, the difference is in their own right as far as the purpose is concerned.
For example, a patient medical record is designed to track the history of a patient at one medical facility over time; a medical record is used by doctors to keep track of how a patient has been taken care of while he or she was at one medical facility.
Medical records do not contain information on the type of care a patient has received while he or she was treated in another facility, but rather only basic information that may be useful for the doctor to assess the condition of the patient at this point.
Health records, on the other hand, are designed more to gather and preserve the data associated with a patient’s health care
These documents are typically stored in a medical facility’s central database and are used primarily to collect and organize the various health records that are relevant to the individual patient. This includes
- The type of health conditions that a person suffers from
- The treatment that is given to the person for those conditions
- How the patient was cared for while in the care of another medical institution
Medical records are also created in order to maintain a record of past treatments and procedures. They may also be used to provide information on any new treatments that are currently available. As the name implies, a health record is a complete and detailed written document that details a patient’s file from start to finish.
It contains his or her birth certificate, death certificate, passport, immunization records, police records, Social Security records, and many other types of records that are kept by a physician’s office or by another entity that maintains a patient’s record. Medical records are then cross-referenced with a patient’s personal record that includes
- His or her health history
- Medical conditions
- Medical histories
- Any other pertinent information about the patient. such as previous treatment history
A typical medical record consists of one or more chapters or sections
- Clinical Overview
- Clinical Information
- General Description
- Diagnostic Considerations
- Patient’s Registry, which includes all the information pertaining to a specific patient’s care
This information includes
- The patient’s name
- Diagnosis and/or treatment
- Any medication prescribed
- Any previous treatments
- Family members
- Medications used
- Discharge dates and times of illness and recovery, any hospital stays, etc
A doctor’s office will usually include a form to assist in filling out medical records, but there are also electronic or manual forms that can be filled out by patients. These forms are easily obtained from the doctor’s office and include instructions for the patient’s use.
It may also ask for certain information on what medical treatment methods have been used with the patient’s consent, including specific drugs that have been used with the patient. While a doctor’s office generally records the details of a patient’s entire medical file, some facilities only keep a portion of it.
Some offices hold a small portion of the information and keep a smaller part, such as a billing and coding section where a doctor can electronically submit insurance claims or other medical information. A doctor’s office will keep other documents that pertain to a patient, such as a
- Discharge order
- When the patient has died or transferred care to another facility
A patient can also request a copy of his or her medical records for review purposes from a doctor’s office if the patient is not satisfied with the current record. Most health insurance companies require a medical record to be filed with them for each patient.
If a patient files an appeal, this process may take longer and may take several consultations with the doctor, but eventually, the doctor’s office should be able to provide the medical records that have been requested.
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