Medical Health Record

  • Cover
  • History

In the USA, major medical education institutions were among the first to adopt the medical record. The New York Hospital began duplicating selected case reports from doctor’s notes into printed clinical and surgical publications for archiving in the institution’s library in 1808 (Gillum, 2018). Data for instructional and historical reasons included; the history of the condition, the factors causing it, the therapies used, and the outcome of the case (Gillum, 2018). They afterward acted as research resources.

Medical Health Record

  • History

Medical and surgical hospitalization services and outpatient services were stored in distinct volumes of records in bound volumes. As a result, a patient’s data was scattered and difficult to access (Gillum, 2018). The casebook, daybook, and journal were among the forms regularly employed by private physicians in the United States and Canada in the nineteenth century.

  • History

To confront the challenge of fragmented, poorly organized data, Henry S. Plummer in1907 at St Mary’s Hospital and the Mayo Clinic, introduced a protocol where each new patient was designated a hospital number, and all information for that patient was merged in a single record (Gillum, 2018). Following World War II, advances in science and medicine were mirrored in significant advancements in the hospital record.

Weed pioneered the problem-oriented medical information system for restructuring and summarizing knowledge in the 1960s. As a result of the early adoption of public health insurance in Europe, governments played an essential role in the creation of the medical record. In the 1970s, initiatives began to overhaul the general practitioner record system, and an EHR was born (Gillum, 2018).

  • Medical Records and Charts

A medical record, also referred to as a medical chart, health record, electronic health record, or electronic medical record (EMR), explains and preserves a patient’s health care history. Its goal is to utilize the content in the record to provide knowledgeable patient care and management.

Patient progress notes, nurse’s cardexes, procedures, any surgical notes, radiological reports, ob-gyn notes, admission documents, discharge documents, pathology findings, history and physical examination details, and test findings are all included in the medical record (Oberg & Villemaire, 2018). It serves as a foundation for the patient treatment plan. It also serves as a legal record, proving that the patient had that specific treatment, whether it be drugs or surgeries (Oberg & Villemaire, 2018).

  • Medical Records and Charts

Medical charts include patient demographics like age, sex, gender, weight, and height. Developmental milestones are also included in medical charts. It entails growth charts of height and weight in the first 5 years of a patient’s life, motor development, cognitive development, social and emotional development, literacy skills, and language comprehension (Gallego, 2018).

Immunization Statistics depict all the vaccines the patient has received and the dates administered. In adults, hepatitis B, COVID-19, and Flu vaccines need to be up-to-date. Medication history and a list of current medications are also necessary. This is important in that it can be able to monitor the patient’s drug interactions. Medical and food allergies are also essential to prevent adverse drug reactions such as steven-johnson syndrome.

Surgical history includes surgery dates, and surgical reports, of both current and past.

Obstetric history in female patients is critical and must encompass the number of pregnancies, complications during birth and pregnancy, pregnancy and birth risk factors and pregnancy outcomes; whether the infant was alive or dead, postpartum blues and postpartum depression, as well as postpartum psychosis and their interventions (Gallego, 2018).

Family History includes prevalent family diseases like heart conditions, cancer, diabetes, and hypertension. Social history includes relationships, previous and present jobs, and community involvement. Social history also includes the patient’s habits, such as alcohol intake, exercise, food, smoking, and sexual history (Gallego, 2018).

  • Medical Records and Charts

At each medical visit, the following information will be entered into the patient’s chart:

The chief complaint is what brought the patient to the hospital on a particular day. History of presenting illness includes when the patient started experiencing the symptoms and the interventions the patient has done. Medical examination entails head-to-toe assessment, vital signs like pulse rate, respiratory rate, blood pressure, temperature, and blood glucose to determine any deviation from the norm, and organ system review (Gallego, 2018).

Assessment and planning are included in the current medical chart, as well as the diagnosis and treatment options, such as prescription medications or surgery. Diagnostic investigations are included lab investigations and test results of lab testing, and imaging results (Gallego, 2018).

  • Pros and Cons of Paper vs. Electronic Health Records

Electronic documentation is typically utilized in combination with traditional paper-based records, and it is reasonable to believe that electronic health records represent a subset of the patient data held in the paper-based record, especially in marginal medical centers where internet and power are scarce (Stausberg et al., 2019). Simultaneous usage of electronic and paper-based patient data results in incompatibilities across the record systems, and documentation consistency in both might be limited.

For various reasons, the paper-based patient record remains the primary source of data management in everyday care delivery (Stausberg et al., 2019). The use of paper-based patient records, both as reminders to healthcare practitioners to report occurrences, such as the progress of a condition and as a tool for practitioner communication, is utilized everywhere (Stausberg et al., 2019).

  • Pros and Cons of Paper vs. Electronic Health Records

EHRs and the capacity to electronically communicate health information can assist nurses in providing greater quality and safer care to patients while also delivering concrete benefits for the business. This is demonstrated by the capacity to improve all elements of patient care, such as safety, efficacy, patient-centeredness, communication, teaching, punctuality, efficiency, and fairness(Abiy et al., 2018).

EHR also improves efficiency and lowers healthcare costs by encouraging preventive medicine and better coordination of healthcare providers, as well as decreasing waste and unnecessary testing, not forgetting improved clinical decision-making by combining patient data from many sources(Abiy et al., 2018).

  • Pros and Cons of Paper vs. Electronic Health Records

Paper records occupy significant space on-site that may be used for revenue-generating operations (Abiy et al., 2018).  Handwritten paper records are sometimes unreadable. When paper documents are strenuous to see, it is quicker to make an error in a patient’s medication regimen (Abiy et al., 2018).

Because EHRs are digital, differing handwriting styles are no longer a challenge, and there is a reduced chance of mistakes in patient care. Paper documents are at risk of being forever lost or discarded. Man hours are also needed to locate any files, and natural calamities can result in the irreversible destruction of paper documents. EHRs are digitally stored on servers that are backed up for safety.

  • Importance of Using Medical Records and Chart

O’Daniel and Rosenstein (2018), for example, discovered that social, relational, and organizational factors lead to communication breakdowns, which have been identified as major contributors to unfavorable clinical occurrences and outcomes. Another study by O’Daniel and Rosenstein (2018) found that patient care priorities fluctuated across members of the medical care team and that verbal communication between team members was uneven.

O’Daniel and Rosenstein (2018) further suggest that more than 1/5 of patients admitted in the U.s.a. had difficulties with the hospital system, such as employees delivering erroneous instructions and staff not identifying which physician is in charge of their treatment.

  • Importance Of Using Medical Records & Chart

For example, the EHR system assists medical practitioners in making clinical decisions. The internet assists healthcare practitioners by giving them the most up-to-date drug information, cross-referencing a patient’s allergy to a medicine, and delivering warnings for drug interactions and other possible patient difficulties that the system flags. Because medical knowledge is always evolving, each of these roles provides healthcare practitioners with the tools they need to provide treatment in a safer and more effective manner.

  • Importance Of Using Medical Records & Chart

For instance, since they provide audit trails, electronic health record systems provide medical companies and HCWs with increased security. With an EHR system, it is possible to immediately discover who accessed a patient’s information, when they did so, and if the access was permitted. An audit will reveal whether someone has access to information that they should not have.

  • Joint Commission and its Importance

The Joint Commission aims to allow and equip healthcare organizations throughout the world to provide the groundwork for excellent treatment and patient safety (Oberg & Villemaire, 2018). The Joint Commission standards can assist health organizations in developing plans to solve the most difficult challenges and identifying critical risks in the patient care experience. The standards examine many parts of the healthcare delivery process to ensure a thorough examination of the patient care experience (Oberg & Villemaire, 2018).

  • Joint Commission and its Importance

Implementing the Joint Commission criteria fosters an outstanding culture throughout the health institution. Furthermore, certification standards give a foundation for disease management and its effective treatment that cuts across all the health care organizations and program structures, which aids in maintaining a continuously high level of quality through effective data-driven productivity improvement (Oberg & Villemaire, 2018).

  • Health Insurance Portability and Accountability Act

The Privacy Rule guidelines govern how enterprises subject to the Privacy Rule utilize and disclose protected health information. The Privacy Rule also includes requirements for patients to comprehend and manage how their health records are used.

The Privacy Rule’s main purpose is to ensure that people’s health information is appropriately secured while permitting the flow of medical data required to deliver and promote high-quality treatment and to safeguard the public’s welfare.  The Privacy Rule allows for vital data use while respecting the privacy of those seeking care and treatment (CDC, 2022).

  • Health Insurance Portability and Accountability Act

HIPAA regulations, which also safeguard the confidentiality and safety of participants’ identifiable patient data and create a variety of personal rights with regard to health details, show the importance of allowing individuals to access and receive a copy of their health records. The HIPAA Privacy Rule, with a few exceptions, gives individuals a legal, binding right to view and get copies of the content in their medical and health records held by their medical care providers.

  • How Joint Commission and HIPAA are Involved in the Creation of this Tool

It is crucial to remember that HIPAA grants patients the authority to verify and obtain a copy of their health data; there is no rule in the HIPAA privacy and security guidelines or the Joint Commission standards that explicitly forbids healthcare professionals from communicating data with patients collaborating with patients at the point-of-care or in governance (IPFCC, 2018). Furthermore, the Joint Commission supports patient participation as well as collaboration with patients in health care reform and improvement to meet quality and safety goals.

  • How Joint Commission and HIPAA is Involved in the Creation of this Tool

The HIPAA Privacy Rule gives patients a legal, binding right to examine and get medical copies of data contained in their medical records stored by their medical providers upon request; hence, HIPAA is engaged in medical records tool creation. Joint Commission standards, on the other hand, assist organizations in developing plans to solve the most difficult challenges and identify critical weaknesses in the patient care experience (IPFCC, 2018).

The standards examine many parts of the patient treatment process, guaranteeing a thorough examination of the care process. This explains how the joint commission contributes to the creation of the medical records tool (IPFCC, 2018).

  • Electronic Medical Records (EMR). Does One Size Fit All? Why or Why Not?

Most EMRs are built for primary care, with one-size-fits-all systems in which treatments are uncommon, diseases vary, and outbound referrals are frequent. The majority of the patient’s data and, in some specialties, nearly half of the practice revenue are connected to procedures and long-term illness care, even though these activities receive little or no attention. The paperless illusion is generated by scanning, faxing, and generic text processors, which give little utility or medical insight in the absence of human interpretation.

  • Electronic Medical Records (EMR). Does One Size Fit All? Why or Why Not?

Due to the complexity of medical processes, stand-alone recordkeeping platforms that transmit scant details with EMRs and tailored laboratories have emerged. These technologies often return a legible document to the EMR. There is limited information in the picture file to modify treatment protocols, diagnostic orders, diagnoses, or follow-up actions in the EMR chart.

Interconnected EMR-Procedure systems from several manufacturers produce a complicated and semi-functional solution with numerous moving pieces, prohibiting experts from providing better treatment at a cheaper cost. This shows that a one-size EMR does not fit all.

References

Abiy, R., Gashu, K., Asemaw, T., Mitiku, M., Fekadie, B., Abebaw, Z., Mamuye, A., Tazebew, A., Teklu, A., Nurhussien, F., Kebede, M., Fritz, F., & Tilahun, B. (2018). A comparison of electronic medical record data to paper records in antiretroviral therapy clinic in Ethiopia: What is affecting the quality of the data? Online Journal of Public Health Informatics, 10(2), e212. https://doi.org/10.5210/ojphi.v10i2.8309

CDC. (2022). Health insurance portability and accountability act of 1996 (HIPAA). Cdc.gov. https://www.cdc.gov/phlp/publications/topic/hipaa.html

CMPA. (2022). CMPA Good Practices Guide – Importance of medical records. Cmpa-Acpm.Ca. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Documentation/importance_of_medical_records-e.html

Gallego, G. (2018). What is a medical chart? Continuum. https://www.carecloud.continuum/what-is-a-medical-chart/

Gillum, R. F. (2018). From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age. The American Journal of Medicine, 126(10), 853–857. https://doi.org/10.1016/j.amjmed.2013.03.024

IPFCC. (2018). HIPAA privacy and security rules and Joint Commission standards are NOT barriers to advancing patient-and family-centered care and building partnerships with patients and families. Ipfcc.org. https://www.ipfcc.org/bestpractices/HIPAA-Factsheet.pdf

Khodyakov, D., Mendoza-Graf, A., Berry, S., Nebeker, C., & Bromley, E. (2019). Return of value in the New Era of biomedical research-one size will not fit all. AJOB Empirical Bioethics, 10(4), 265–275. https://doi.org/10.1080/23294515.2019.1666175

O’Daniel, M., & Rosenstein, A. H. (2018). Professional Communication and Team Collaboration. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK2637/

Oberg, D., & Villemaire, L. (2018). Grammar and writing skills for the health professional. Cengage Learning.

Stausberg, J., Koch, D., Ingenerf, J., & Betzler, M. (2019). Comparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure codes. Journal of the American Medical Informatics Association: JAMIA, 10(5), 470–477. https://doi.org/10.1197/jamia.M1290