Medical record
Encyclopedia
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.. 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 maintenance of complete and accurate medical 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 maintained by health care providers, but advances in online data storage have led to the development of personal health record
s (PHR) that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association.
Because many consider information in medical records to be sensitive personal information covered 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. .
The traditional medical record for inpatient care can include admission note
s, on-service notes, progress note
s (SOAP note
s), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
Personal health record
s combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.http://www.mckinley.uiuc.edu/clinics/medrec/medrec-faq.html.
medical students
/resident physicians, to provide data for internal hospital auditing
and quality assurance
, and to provide data for medical research.
The contents are written by medical providers, and patients until relatively recently had no say in what was contained in it. Recent advances in health care records privacy and access rules have generally provided for a patient's right to review and have recorded in the medical record objections to the accuracy of certain entries.
The advent of electronic medical record
s has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic
out of a desire to simplify patient tracking and to allow for medical research.
Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.
is a longitudinal
record of what has happened to the patient since birth. It chronicles disease
s, major and minor illness
es, 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
Obstetric history
Medications and medical allergies
Family history
Social history
Habits
Immunization history
Growth chart and developmental history
" method of documentation for each visit. Each encounter will generally contain the aspects below:
Chief complaint
History of the present illness
Physical examination
Assessment and plan
and are entered by all members of the health-care team (doctors, nurses, physical therapists, 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.
) radiology
examinations (e.g., X-ray
s), pathology
(e.g., biopsy
results), or specialized testing (e.g., pulmonary function testing
) are included. Often, as in the case of X-ray
s, a written report of the findings
is included in lieu of the actual film.
s, 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.
There are several types of information needed to be recorded while tracing the state of a patient's daily health:
1. Vital Signs: Body Temperature, Pulse Rate(Heart Rate), Blood Pressure and Respiratory Rate.
2. Intake: Medication, Fluid, Nutrition, Water and Blood, etc.
3. Output: Blood, Urine, Excrement, Vomitus and Sweat, etc.
4. Observation of Pupil size.
5. Capability of four limbs of body
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.
, 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. Electronic versions require an electronic signature
.
is a basic human right. Hence a patient's record should belong to the patient, but it seldom happens so.
, 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 per the Health Insurance Portability and Accountability Act
. 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.
, ownership of the NHS
's medical records belong to the Department of Health, and this is taken by some to mean copyright also belongs to the authorities.
, 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 the guidelines of the Health Insurance Portability and Accountability Act
(HIPAA).
The rules become more complicated in special situations.
Capacity
Medical emergency
Research, auditing, and evaluation
Risk of death or harm
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 wellbeing (e.g., 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.
, medical records are required for the lifetime of a patient and legally for as long as 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 deaths at the hands of doctors committing murders, as in the Harold Shipman
case).
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
's medical history
Medical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
and care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
across time within one particular health care provider's jurisdiction.. 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 maintenance of complete and accurate medical 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 maintained by health care providers, but advances in online data storage have led to the development of personal health record
Personal health record
A personal health record or PHR is a health record where health data is curated by an individual user themselves. This stands in contrast with the more widely used electronic medical record which is held by institutions such as a hospital and contains data entered by clinicians or billing data in...
s (PHR) that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association.
Because many consider information in medical records to be sensitive personal information covered 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. .
Purpose
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.The traditional medical record for inpatient care can include admission note
Admission note
An admission note is part of a medical record that documents the patient's status, reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care...
s, on-service notes, progress note
Progress note
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. Reassessment data may be recorded in the Progress Notes, Master...
s (SOAP note
SOAP note
The SOAP note is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note...
s), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
Personal health record
Personal health record
A personal health record or PHR is a health record where health data is curated by an individual user themselves. This stands in contrast with the more widely used electronic medical record which is held by institutions such as a hospital and contains data entered by clinicians or billing data in...
s combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.http://www.mckinley.uiuc.edu/clinics/medrec/medrec-faq.html.
Auxiliary purpose
In addition, the individual medical record anonymised may serve as a document to educateEducation
Education in its broadest, general sense is the means through which the aims and habits of a group of people lives on from one generation to the next. Generally, it occurs through any experience that has a formative effect on the way one thinks, feels, or acts...
medical students
Medical school
A medical school is a tertiary educational institution—or part of such an institution—that teaches medicine. Degree programs offered at medical schools often include Doctor of Osteopathic Medicine, Bachelor/Doctor of Medicine, Doctor of Philosophy, master's degree, or other post-secondary...
/resident physicians, to provide data for internal hospital auditing
Clinical audit
Clinical audit is a process that has been defined as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change"....
and quality assurance
Quality control
Quality control, or QC for short, is a process by which entities review the quality of all factors involved in production. This approach places an emphasis on three aspects:...
, and to provide data for medical research.
Contents
A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further information varies with the individual medical history of the patient.The contents are written by medical providers, and patients until relatively recently had no say in what was contained in it. Recent advances in health care records privacy and access rules have generally provided for a patient's right to review and have recorded in the medical record objections to the accuracy of certain entries.
Media applied
Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.The advent of electronic medical record
Electronic medical record
An electronic medical record is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office...
s has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic
Mayo Clinic
Mayo Clinic is a not-for-profit medical practice and medical research group specializing in treating difficult patients . Patients are referred to Mayo Clinic from across the U.S. and the world, and it is known for innovative and effective treatments. Mayo Clinic is known for being at the top of...
out of a desire to simplify patient tracking and to allow for medical research.
Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.
Medical history
The medical historyMedical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
is a longitudinal
Longitudinal study
A longitudinal study is a correlational research study that involves repeated observations of the same variables over long periods of time — often many decades. It is a type of observational study. Longitudinal studies are often used in psychology to study developmental trends across the...
record of what has happened to the patient since birth. It chronicles disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
s, major and minor illness
Illness
Illness is a state of poor health. Illness is sometimes considered another word for disease. Others maintain that fine distinctions exist...
es, as well as growth landmarks
Growth landmarks
Growth landmarks are parameters measured in infants, children and adolescents which help gauge where they are on a continuum of normal growth and development.Growth landmarks have also been used for determination of abnormal growth as well.-External links:...
. 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 surgerySurgerySurgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
performed for the patient. It may have dates of operations, operative reportOperative reportAn Operative report is a report written to document the details of a surgery. In most American states and in many other jurisdictions patients have a right to receive a copy of their medical records, including the operative report...
s, and/or the detailed narrative of what the surgeonSurgerySurgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
did.
Obstetric history
- The obstetricObstetricsObstetrics is the medical specialty dealing with the care of all women's reproductive tracts and their children during pregnancy , childbirth and the postnatal period...
history lists prior pregnanciesPregnancyPregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
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 familyFamilyIn human context, a family is a group of people affiliated by consanguinity, affinity, or co-residence. In most societies it is the principal institution for the socialization of children...
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 chartPedigree chartA pedigree chart is a diagram that shows the occurrence and appearance or phenotypes of a particular gene or organism and its ancestors from one generation to the next, most commonly humans, show dogs, and race horses....
. 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 relationshipInterpersonal relationshipAn interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
s of the patient, his/her careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of communityCommunityThe term community has two distinct meanings:*a group of interacting people, possibly living in close proximity, and often refers to a group that shares some common values, and is attributed with social cohesion within a shared geographical location, generally in social units larger than a household...
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 (e.g. occupational exposure to asbestos).
Habits
- Various habits which impact health, such as tobaccoTobaccoTobacco is an agricultural product processed from the leaves of plants in the genus Nicotiana. It can be consumed, used as a pesticide and, in the form of nicotine tartrate, used in some medicines...
use, alcoholAlcoholIn chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....
intake, exercise, and dietDiet (nutrition)In nutrition, diet is the sum of food consumed by a person or other organism. Dietary habits are the habitual decisions an individual or culture makes when choosing what foods to eat. With the word diet, it is often implied the use of specific intake of nutrition for health or weight-management...
are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientationSexual orientationSexual orientation describes a pattern of emotional, romantic, or sexual attractions to the opposite sex, the same sex, both, or neither, and the genders that accompany them. By the convention of organized researchers, these attractions are subsumed under heterosexuality, homosexuality,...
.
Immunization history
- The history of vaccinationVaccinationVaccination is the administration of antigenic material to stimulate the immune system of an individual to develop adaptive immunity to a disease. Vaccines can prevent or ameliorate the effects of infection by many pathogens...
is included. Any blood tests proving immunityImmune systemAn immune system is a system of biological structures and processes within an organism that protects against disease by identifying and killing pathogens and tumor cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own...
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 and 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 (i.e., 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 "SOAPSOAP note
The SOAP note is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note...
" method of documentation for each visit. Each encounter will generally contain the aspects below:
Chief complaint
Chief complaint
The Chief Complaint formally known as CC in the medical field, or termed Presenting Complaint in the UK, is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medicalencounter...
- 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
History of the present illness
In a medical encounter, a history of the present illness refers to a detailed interview prompted by the chief complaint or presenting symptom ....
- A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
Physical examination
- The physical examinationPhysical examinationPhysical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
is the recording of observations of the patient. This includes the vital signs , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms 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 and Prescriptions
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 noteSOAP note
The SOAP note is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note...
and are entered by all members of the health-care team (doctors, nurses, physical therapists, 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 (e.g., complete blood countComplete blood count
A complete blood count , also known as full blood count or full blood exam or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood...
) radiology
Radiology
Radiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualized within the human body. Radiologists use an array of imaging technologies to diagnose or treat diseases...
examinations (e.g., X-ray
X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
s), pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
(e.g., biopsy
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
results), or specialized testing (e.g., pulmonary function testing
Spirometry
Spirometry is the most common of the pulmonary function tests , measuring lung function, specifically the measurement of the amount and/or speed of air that can be inhaled and exhaled...
) are included. Often, as in the case of X-ray
X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
s, a written report of the findings
Medical findings
Medical findings will signify the collective physical and psychological occurrences of patients surveyed by a medical doctor. The survey is composed of physical examinations by the doctor's senses and simple medical devices, which build clinical findings. If necessary, the results are proofed by...
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 unitIntensive Care Unit
thumb|220px|ICU roomAn intensive-care unit , critical-care unit , intensive-therapy unit/intensive-treatment unit is a specialized department in a hospital that provides intensive-care medicine...
s, informed consent
Informed consent
Informed consent is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards. As a literal matter, in the absence of fraud, it is redundant. An informed consent can be said to have been given based upon a clear appreciation and understanding of the...
forms, EKG tracings, outputs from medical devices (such as pacemakers
Artificial pacemaker
A pacemaker is a medical device that uses electrical impulses, delivered by electrodes contacting the heart muscles, to regulate the beating of the heart...
), chemotherapy
Chemotherapy
Chemotherapy is the treatment of cancer with an antineoplastic drug or with a combination of such drugs into a standardized treatment regimen....
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.
There are several types of information needed to be recorded while tracing the state of a patient's daily health:
1. Vital Signs: Body Temperature, Pulse Rate(Heart Rate), Blood Pressure and Respiratory Rate.
2. Intake: Medication, Fluid, Nutrition, Water and Blood, etc.
3. Output: Blood, Urine, Excrement, Vomitus and Sweat, etc.
4. Observation of Pupil size.
5. Capability of four limbs of body
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 contain information about race and religionReligion
Religion is a collection of cultural systems, belief systems, and worldviews that establishes symbols that relate humanity to spirituality and, sometimes, to moral values. Many religions have narratives, symbols, traditions and sacred histories that are intended to give meaning to life or to...
as well as workplace and type of occupation
Employment
Employment is a contract between two parties, one being the employer and the other being the employee. An employee may be defined as:- Employee :...
. 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
In the United StatesUnited States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, 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. Electronic versions require an electronic signature
Electronic signature
An electronic signature, or e-signature, is any electronic means that indicates either that a person adopts the contents of an electronic message, or more broadly that the person who claims to have written a message is the one who wrote it . By comparison, a signature is a stylized script...
.
Informational self-determination
The informational self-determinationInformational self-determination
The term informational self-determination was first used in the context of a German constitutional ruling relating to personal information collected during the 1983 census....
is a basic human right. Hence a patient's record should belong to the patient, but it seldom happens so.
Ownership for patient's record
Ownership and keeping of patient's records varies from country to country.US law and customs
In the United StatesUnited States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, 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 per the Health Insurance Portability and Accountability Act
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act of 1996 was enacted by the U.S. Congress and signed by President Bill Clinton in 1996. It was originally sponsored by Sen. Edward Kennedy and Sen. Nancy Kassebaum . Title I of HIPAA protects health insurance coverage for workers and their...
. 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.
UK law and customs
In the United KingdomUnited Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
, ownership of the NHS
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
's medical records belong to the Department of Health, and this is taken by some to mean copyright also belongs to the authorities.
German law and customs
In Germany ownership of patient's records is not explicitly codified. Hence traditional keeping of patient's records is with the hospitals and the practitioners. There is no comprehensive data set containing all information on one patient in one file defined yet. Since 1995, patients are identified via a health insurance card that includes name and address information as well as an ID assigned by the insurance provider. An upgrade to advanced health insurance cards (Elektronische Gesundheitskarte) that can store additional medical information was planned for 2006. Discussion on the benefit, the associated cost, and on data privacy issues is still ongoing as of 2011.Accessibility
In the United StatesUnited States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, 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
Consent
Consent refers to the provision of approval or agreement, particularly and especially after thoughtful consideration.- Types of consent :*Implied consent is a controversial form of consent which is not expressly granted by a person, but rather inferred from a person's actions and the facts and...
for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under the guidelines of the Health Insurance Portability and Accountability Act
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act of 1996 was enacted by the U.S. Congress and signed by President Bill Clinton in 1996. It was originally sponsored by Sen. Edward Kennedy and Sen. Nancy Kassebaum . Title I of HIPAA protects health insurance coverage for workers and their...
(HIPAA).
The rules become more complicated in special situations.
Capacity
- When a patient does not have capacityCapacity (law)The capacity of both natural and legal persons determines whether they may make binding amendments to their rights, duties and obligations, such as getting married or merging, entering into contracts, making gifts, or writing a valid will...
(is not legally able) to make decisions regarding his or her own care, a legal guardianLegal guardianA legal guardian is a person who has the legal authority to care for the personal and property interests of another person, called a ward. Usually, a person has the status of guardian because the ward is incapable of caring for his or her own interests due to infancy, incapacity, or disability...
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 comaComaIn medicine, a coma is a state of unconsciousness, lasting more than 6 hours in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound, lacks a normal sleep-wake cycle and does not initiate voluntary actions. A person in a state of coma is described as...
tose, minors (unless emancipatedEmancipation of minorsAn emancipated minor is a minor who is allowed to conduct a business or any other occupation on their own behalf or for their own account outside the influence of a parent or guardian. The minor will then have full contractual capacity to conclude contract with regard to the business. Whether...
), and patients with incapacitating psychiatricPsychiatryPsychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...
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 previously drafted (such as an advance directive)
Research, auditing, and evaluation
- Individuals involved in medical research, financial or management auditAuditThe general definition of an audit is an evaluation of a person, organization, system, process, enterprise, project or product. The term most commonly refers to audits in accounting, but similar concepts also exist in project management, quality management, and energy conservation.- Accounting...
s, 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 (i.e., 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. Redmondhttp://biotech.law.lsu.edu/cases/medrec/42_USC_29dd-2.htm.
In the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
, the Data Protection Acts and later the Freedom of Information Act 2000
Freedom of Information Act 2000
The Freedom of Information Act 2000 is an Act of Parliament of the Parliament of the United Kingdom that creates a public "right of access" to information held by public authorities. It is the implementation of freedom of information legislation in the United Kingdom on a national level...
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 wellbeing (e.g., 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. In the United KingdomUnited Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
, medical records are required for the lifetime of a patient and legally for as long as 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 deaths at the hands of doctors committing murders, as in the Harold Shipman
Harold Shipman
Harold Fredrick Shipman was an English doctor and one of the most prolific serial killers in recorded history with 218 murders being positively ascribed to him....
case).
Abuses
- The outsourcingOutsourcingOutsourcing is the process of contracting a business function to someone else.-Overview:The term outsourcing is used inconsistently but usually involves the contracting out of a business function - commonly one previously performed in-house - to an external provider...
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 felonyFelonyA felony is a serious crime in the common law countries. The term originates from English common law where felonies were originally crimes which involved the confiscation of a convicted person's land and goods; other crimes were called misdemeanors...
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 historyMedical historyThe medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
- Medical lawMedical lawMedical law is the branch of law which concerns the prerogatives and responsibilities of medical professionals and the rights of the patient. It should not be confused with medical jurisprudence, which is a branch of medicine, rather than a branch of law....
- Electronic medical recordElectronic medical recordAn electronic medical record is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office...
- Electronic health recordElectronic Health RecordAn electronic health record is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations...
- Hospital information systemHospital information systemThere are various titles and acronyms which all declare similar approaches to managing the information flow and storage in hospital routine services, as*Hospital Information System , or*Healthcare Information System, or...
- Physical examinationPhysical examinationPhysical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
- Physician-patient privilegePhysician-patient privilegePhysician–patient privilege is a legal concept, related to medical confidentiality, that protects communications between a patient and his or her doctor from being used against the patient in court. It is a part of the rules of evidence in many common law jurisdictions...
- Online office suite
External links
- Personal Medical Records from MedlinePlusMedlinePlusMedlinePlus is a free Web site that provides consumer health information for patients, families, and Health care providers. The site brings together information from the United States National Library of Medicine, the National Institutes of Health , other U.S. government agencies, and...
- American Health Information Management Association
- Medical Record Privacy - Electronic Privacy Information CenterElectronic Privacy Information CenterElectronic Privacy Information Center is a public interest research group in Washington, D.C. It was established in 1994 to focus public attention on emerging civil liberties issues and to protect privacy, the First Amendment, and constitutional values in the information age...
(EPIC) - The ICMCC portal on access to electronic medical records. The portal includes a blog to share and discuss experiences for both patients and clinicians as well as an extended overview of relevant literature.
Organizations dealing with medical records
- ASTM Continuity of Care RecordContinuity of Care RecordContinuity of Care Record is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society , the Healthcare Information and Management Systems Society , the American Academy of Family Physicians , the American Academy of Pediatrics , and other...
- a patient health summary standard based upon XMLXMLExtensible Markup Language is a set of rules for encoding documents in machine-readable form. It is defined in the XML 1.0 Specification produced by the W3C, and several other related specifications, all gratis open standards....
, the CCR can be created, read and interpreted by various EHR or Electronic Medical RecordElectronic medical recordAn electronic medical record is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office...
(EMR) systems, allowing easy interoperability between otherwise disparate entities. - American Health Information Management Association