8/12/2019 Patient Record Maintenance

1/2

Patient Record Maintenance

The terms medical record, health record, and medical chart are used somewhat

interchangeably to describe the systematic documentation of a single patient's medical history

and care across time within one particular health care provider's jurisdiction.[1]

. The medical

record includes a variety of types of "notes" entered over time by health care professionals,recording observations and administration of drugs and therapies, orders for the administration of

drugs and therapies, test results, x-rays, reports, etc. The maintenanceof complete and accuratemedical records is a fundamental requirement of health care providers and is generally enforced

as a licensing or certification prerequisite.

The terms are used for both the physical folder that exists for each individual patient and for the

body of information found therein.

Medical records have traditionally been compiled and maintainedby health care providers, but

advances in online data storage have led to the development of personal health records (PHR)

that are maintained by patients themselves, often on third-party websites. This concept issupported by US national health administration entities and by AHIMA, the American Health

Information Management Association.

A medical record folder being pulled from the records

Because many consider information in medical records to be sensitive personal informationcovered by expectations of privacy, many ethical and legal issues are implicated in their

maintenance, such as third-party access and appropriate storage and disposal. Although the

storage equipment for medical records generally is the property of the health care provider, the

actual record is considered in most jurisdictions to be the property of the patient, who may obtain

copies upon request.

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 rules governing production, ownership,accessibility, and destruction. There is some controversy regarding proof verifying the facts, or

absence of facts in the record, apart from the medical record itself.

Demographics

Demographics include patient information that is not medical in nature. It is often information to

locate the patient, including identifying numbers, addresses, and contact numbers. It may containinformation about race and religion as well as workplace and type of occupation. 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.

Production

http://en.wikipedia.org/wiki/Patienthttp://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Medical_record#cite_note-0http://en.wikipedia.org/wiki/Medical_record#cite_note-0http://en.wikipedia.org/wiki/Medical_record#cite_note-0http://en.wikipedia.org/wiki/Personal_health_recordhttp://en.wikipedia.org/wiki/Ethicalhttp://en.wikipedia.org/wiki/Legalhttp://en.wikipedia.org/wiki/Legal_documenthttp://en.wikipedia.org/wiki/Demographichttp://en.wikipedia.org/wiki/Race_%28classification_of_human_beings%29http://en.wikipedia.org/wiki/Religionhttp://en.wikipedia.org/wiki/Employmenthttp://en.wikipedia.org/wiki/Employmenthttp://en.wikipedia.org/wiki/Religionhttp://en.wikipedia.org/wiki/Race_%28classification_of_human_beings%29http://en.wikipedia.org/wiki/Demographichttp://en.wikipedia.org/wiki/Legal_documenthttp://en.wikipedia.org/wiki/Legalhttp://en.wikipedia.org/wiki/Ethicalhttp://en.wikipedia.org/wiki/Personal_health_recordhttp://en.wikipedia.org/wiki/Medical_record#cite_note-0http://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/Patient

8/12/2019 Patient Record Maintenance

2/2

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 out with a

single line and initialed by the author. Orders and notes must be signed by the author. Electronicversions require anelectronic signature.

Ownership for patient's record

Ownership and keeping of patient's records varies from country to country.

Abuses

Theoutsourcing of medical record transcription and storage has the potential to violatepatient-physician confidentiality by possibly allowing unaccountable persons access to

patient data.

Falsification of a medical record by a medical professional is afelony in most UnitedStates jurisdictions.

Governments have often refused to disclose medical records of military personnel whohave been used as experimental subjects.

http://en.wikipedia.org/wiki/United_Stateshttp://en.wikipedia.org/wiki/Electronic_signaturehttp://en.wikipedia.org/wiki/Outsourcinghttp://en.wikipedia.org/wiki/Felonyhttp://en.wikipedia.org/wiki/Felonyhttp://en.wikipedia.org/wiki/Outsourcinghttp://en.wikipedia.org/wiki/Electronic_signaturehttp://en.wikipedia.org/wiki/United_States