The medical record serves many purposes, including its role in evaluating a potential or actual case.
Medical Records – top uses
1. Written documentation provides historical data that could be used for diagnosing the patient’s current medical episode as well as future medical events. Accurate medical information about previous health conditions, allergies, treatments, and outcomes are contained in the medical record.
2. Contributions to the medical record are made by healthcare professionals and in turn provide authenticity of the data. Laboratory and radiology results, outpatient and inpatient procedures, and notes from specialists consulted on the patient’s behalf become a permanent record.
3. Access to a patient’s health history and medical data provides continuity of care, promotes patient safety, and eliminates duplication of diagnostic testing and procedures.
4. As a written document, the medical record also serves as a legal record of the care the patient received, results of diagnostic testing, medications prescribed for the patient, and outcomes resulting from treatments or medications.
5. Review of the written records affords the hospital a means to assess a physician’s abilities and competency. Outcomes achieved through the physician’s care and treatment of a patient can be evaluated. Chart surveys and reviews are usually conducted as a means to capture data on adverse outcomes.
If corrective actions are required to improve a physician’s practice of medicine, the appropriate measures can be addressed through the medical staff committee and department chair. Patterns of adverse reactions and negative outcomes for patients, validated through statistical analysis, are presented to the appropriate physician with recommendations for improvement.
6. Documentation of diagnostic testing and procedures can be collected for statistical data. The organization can determine how often procedures or diagnostic tests are ordered. These data can be used to justify changes to a department’s hours of operation, adjusting number of personnel, or a department relocation or remodeling to accommodate the volume.
7. Facilities also are subject to health department, Joint Commission and other healthcare organizations that conduct audits of the hospital. Data obtained from patients’ medical records are used to evaluate whether the facility receives the license, accreditation, or certification associated with the surveying entity. Evaluation of whether or not the healthcare organization has complied with the accepted standards of care associated with the surveying entity is made during the survey.
It is critical for the healthcare organization to meet these standards in order to achieve and maintain a reputation for high quality patient care, to attract competent medical staff, and to compete in the healthcare market place.
8. Physicians and healthcare providers can review previous health records to obtain accurate patient data regarding any surgery, injury, medical conditions, medications ordered, diagnostic testing, therapies provided, dates of treatment, and the patient’s tolerance or reaction to any of the above medical encounters.
This provides an opportunity for the physician to avoid repeating unnecessary diagnostic testing, expedites patient care by avoiding unnecessary delays in treatment, and promotes safer patient care by avoiding therapies and medications that previously resulted in negative patient reactions or are medically contraindicated.
9. Providing statistical analysis to physicians and healthcare professionals is another value derived through the use of the written medical record. With proper authority, they may analyze records specific to their specialty area, determine volume of patients treated within a certain period of time, and calculate how many procedures and consultations they have performed.
10. Medical records are used to evaluate the professionals’ medical competency for performing specific procedures and to qualify for appropriate certification or credentialing. Some procedures are required to be performed under supervision for a specific number of times before healthcare providers may perform the procedure on their own.
11. The record is also of value when used to support and defend against legal actions. The patient record, as the legal documentation of treatment provided by and recommendations made by healthcare professionals, is the only recognized means accepted by the legal system for protecting the healthcare professionals’ legal interests.
12. A patient’s medical record generates value for medical research and teaching. The legal status of the record certifies it as an authentic data source. This authenticity renders the data useful and accurate for researchers and other healthcare professionals in their efforts to develop new theories, treatments, and processes.
Modified from Mila Carlson, PhD RN CLNC CNLCP Adoption Rates and Barriers to Implementation of Electronic Health Records in Physician Office Practices In Northwestern Illinois, Dissertation Presented to the Faculty of the School of Health and Public Administration, Warren National University
You want to be able to expedite the review of electronic records. You know that electronic medical record use will increase as more facilities and physician offices invest in this technology.
- Do you want to sharpen your skills in understanding the intricacies of electronic medical records (EMRs)?
- Are you an attorney who needs to probe the details of an EMR but doesn’t know what information is hidden?
- Do you need to analyze the information in reams of printed EMRs?