MEDICAL RECORDS

Introduction
 First Medical Record unit was established in1667 at St. Hospital, England.
 Followed by practice of maintaining patient register in Pennsylvania Hospital,
USA in 1792.
 Idea of proper Medical Records in form of standardized inpatients record came
in USA from the American College of Physicians and American College of
Surgeons in the last quarter of the 26th century.
 In India Bhore committee 1946 First stressed the importance of keeping Medical
Records.
 Reiterated by MUDALIAR Committee in 1962.
 Subsequently, Health Hospitals review committee (Jain committee and Rao
committee) highlighted poor state of Medical Records and recommended the
establishment of a proper medical records section in each hospitals
 With technical advancement, computers are extensively used for record
generation, Analysis and retrieval.
 Microfilming has also been introduced for easy storage and retrieval.

Medical Records: A Brief History

Simply by virtue of being alive, each man, woman, and child has a history. And in this
technology-enabled age of the Quantified Self, more and more people are taking an active
interest in their personal history—downloading apps to track calories and mood swings,
blogging about runs and test scores. But arguably the most important record is your medical
record—and for people born in the past century, that record has advanced in both importance
and technology.

Why Does It Matter?

The purpose of a medical record is to centralize information that helps patients and their
doctors make well-informed decisions when sorting through the patient’s health and treatment
options. Today, a medical record might include material on the patient’s genes, environment,
diet, lifestyle, and treatment history. Doctors add to these records every time you sit on their
tables, and individuals need access to these records to secure life insurance, provide evidence
of immunization, and so forth.

Low-tech and Low-info Beginnings

Prior to 1900, there was no standard method for keeping medical records. In fact, many doctors
didn’t even touch their patients except to check a pulse; many of their observations centered
on studying the patient’s complexion, urine, and other excretions. So there wasn’t much to
write down.

Some more substantial narratives did exist; the ancient Greeks wrote down advice for patients,
lessons for doctors, and stories of particularly notable diseases. This practice was revived in the
14th century, then again with a scientific revolution in the 16th century—marked by a growing
scholarly interest in the natural world and the inner workings of the body—fueled the
expansion of this practice and the publishing of medical “observations.”

One of the most extensive surviving collections of medical records from this time were written
by Simon Forman and Richard Napier; you can read more about their work at The Casebooks
Project.
But they were the exception to the rule. Other doctors might have kept account books, a list of
patients along with their payments for treatments and prescriptions—but that was usually as
far as they got.

The Rise of Hospitals and Medical Education

In the second half of the 19th century, two developments drove the establishment of more
official medical records in the Western world: public hospitals began to emerge, and medical
knowledge grew exponentially.

In the United States, the migration from home health care to being treated in public hospitals
was a product of urbanization and the rapid evolution of medicine. For example, the new-found
ability to sterilize medical equipment around 1880 opened new doors for surgeons.

Despite these developments, there still weren’t any standards dictating what information to
record, so it was a challenge for doctors to compare cases or trace how a doctor arrived at a
diagnosis.

The Modern Age

In the 1960s, the introduction of computers into the medical field paved the road for the
standardization and sharing of medical records. The ability to log a consistent set of information
allowed doctors to track their patients over time and provide evidence of their decision making
and follow through.

Beyond providing the patient with their medical history, these new modern medical records
had a few other practical purposes:

Coinciding with an increase in medical malpractice litigation, the thorough medical record
became an important legal tool should the doctor be sued (especially if the patient had a poor
outcome).

In terms of insurance, the medical record began to be used to warrant the bill sent to the
insurer as well as to determine the patient’s rates and denials.

A large number of standardized medical records allowed researchers to aggregate useful data
in their study of disease and treatment, further advancing the field of medicine. In fact the
medical coding system is meant to help track the prevalence of illness and the efficacy of
treatment in all sorts of patients.

The 1980s and 90s saw growth in the deployment of various computerized health care
programs, including software for hospital admission registration and master patient indexes.

But many of these programs couldn’t communicate across departments—they were tagged as
“source” systems and unviewable to other departments, let alone other hospitals.

A New Revolution

In 1996, the U.S. Congress passed the Health Insurance Portability and Accountability Act
(HIPAA), which required the establishment of national standards for electronic health records
(EHR). In effect, HIPAA both furthered the digitation of patients’ diagnostic and treatment data
and created a lot of complexity thanks to the thousands of codes used to track that data.

The concept of a national centralized server model of health care data—which would allow
many different providers to communicate and share patient records—is not always a popular
one, as it carries risks involving privacy and security of information.

But the need for expanded EHRs was clear—it could potentially help avoid costly, life-and-death
mistakes. In his January 2004 State of the Union address, President George W. Bush called out
the issue directly: “By computerizing health records, we can avoid dangerous medical mistakes,
reduce costs and improve care.”
The passage of President Barack Obama’s Affordable Care Act in 2010 introduced new
reporting requirements for EHRs. Medical professionals are bracing themselves for a number of
changes related to coding and electronic record keeping.

Medical Records

 This the name that is given to the bundle of documents that belong to the person who is
in hospital and show all actions taken by the hospital bout the person’s illness
 a record of a patient's medical information (as medical history, care or treatments
received, test results, diagnoses, and medications taken)

What Are Medical Records?

Each time you climb up on a doctor's exam table or roll up your sleeve for a blood draw,
somebody makes a note of it in your medical records. Back in the day, your doctor scribbled
notes on a paper chart. That still happens sometimes, but many health care providers now keep
electronic records. You might hear medical people call these EHRs — short for electronic health
records.

Electronic records make it easier for all your doctors to see the same information. So if your
dermatologist wants to give you a prescription, he or she can check to see if other doctors have
given you medicines that might react badly with the new one. Having a central record like this
can help doctors give the best care — and take some of the burden of remembering off the
patient.

It's still good to know about your medical records, though. At some point, you'll need to get
information from them, like if a college or new job needs to see a record of
your immunizations before you can start. Or you might have chosen a new doctor and want him
or her to know your full medical history.

As you start taking charge of your own medical care, it helps to know what's in your medical
records, how you can get them when you need to, who else is allowed to see them, and what
laws are in place to keep them private.

What are in Medical Records?

You might picture your medical records as one big file in a central storage facility somewhere.
But actually your records are in lots of different places. Each specialist who treats you keeps his
or her own file, and they're all part of your medical records.

Even electronic records aren't simple. There are different programs and software, and not all
medical offices use the same system. For that reason, some states now manage records in a
way that lets all your information be shared between different health care providers.

Your medical records contain the basics, like your name and your date of birth. They also
include the information you give to your family physician, dentist, or other specialist during an
examination.

So your answers to all those questions doctors ask — like how you're feeling that day — go into
your records. Your records also have the results of medical tests, treatments, medicines, and
any notes doctors make about you and your health.
Why are medical records important?
 Medical records are important to you for many reasons. Medical records can be used to:
 Support reimbursement for health services provided
 Provide evidence of injury and treatment for workers’ compensation
 Provide evidence of disability for disability insurance
 Identify people who have had a specific treatment when it has been discovered that this
treatment caused some adverse events
 Study disease trends to identify potential environmental or genetic causes
 Track changes in your physical findings such as growth of a mole. Baselines are recorded
so changes are recognized.

Different Types of Medical Record's

 This type of medical record contain all the information of the patient's past medical
history as in office visits, diagnostics, treatments and so on. All of these information is
confidential and disclosed information.

POMR (Problem Oriented Medical Record)

 is a method of recording data about the health status of the patient. This method helps
find the problem and a way to solve it. There are five components of the POMR.

1. Data Base: History, Physical Exam & Laboratory Data

2. Complete Problem List

3. Initial Plans

4. Daily Progress Note

5. Final Progress Note or Discharge Summary

All of these components have proved that it is a great way of diagnosing a patient and finding
treatment for them.

LAB REPORT

 are results of test that were done on clinical specimens in order to get information
about the health of a patient as pertaining to the diagnosis, treatment, and prevention
of disease.

OPERATIVE REPORT

 is a document produced by a surgeon or physician who have participated in a surgical

intervention which has details about the findings, the procedure used, the specimens
removed, the preoperative and postoperative diagnoses and the names of the primary
surgeon and assistants.

HIPAA

 regulations forbid an employee to hand medical records to anyone at anytime. Before

one can release any type of information about a patient they must consult the patient
first and have the patient sign release forms.
INFORMATION

 is fill by the patient's last name and first letter of the name along with the birth date.
This type of recording information is east to organize because now it is done by
computers so there is less filling to go through and it is protected by passwords only
health care providers can access.

PROTECTING INFORMATION

 Protecting these information from the public eye if important. HIPAA regulates that
these information is not seen by anyone who is not HIPAA certified. These information
should be stored in a safe place where it not easy to be seen by the public and if these
information is kept electronically it should be protected by a password only employees
or employ of the facility can access it.

There are different types of medical reports all containing different information about the
patient. Each document should be stored in a safe place away from the public who are not
HIPAA certified. Each document is filled by last name then by first name at times also by birth
date. Medical records are under release under certain circumstances and at times only with the
authorization of the patient.

When the patient's record is need for billing or other administrative purposes there is no need
to acquire a release. Also when it comes to government conducting an investigation of physical
abuse, substance abuse, communicable diseases, or prescription drugs, the patient does not
sign a consent to release theses records.

SOAP

 is a document that health providers use to create a patient's medical chart.

SUBJECTIVE

 Describes the patient's current condition.

OBJECTIVE

 the patient's status (vital signs, weight, etc.)

ASSESSMENT

 Diagnoses for the medical visit.

PLAN

 Treatment of the patient.

There are Three Categories Medical Records are filled in.
ACTIVE

 are files of patients who have been in the office within the last few years. These files are
the main and easiest to reach in the office.

INACTIVE

 are files of patients who have not visit the office within the last few years usually within
five years. All of these files are storage way in another location. The inactive files have
not been terminated they can still be reach.

CLOSED

 are files that are sent to an archive. These files are from patients who are no longer
patients to the physician or who have passed away. The files are kept by the law.
 Laboratory Reports
 Unauthorized Release
 Operative Report
 Filling Laboratory Reports
 Medical Records

The physician legally owns the medical records but the patient has the right to authorize who
can and cannot see their medical record. If the person is a minor some information can be kept
confidentially but other information the parent or legal guardian can access it.

 Special Cases
 Handling Medical Records

Substance abuse is an exception. The Confidentiality of Alcohol and Drug Abuse, Patient
Records prohibits information regarding substance abuse and treatment from being release
without specific written authorization from the patient but they can be revoked at the patient's
discretion.

Lab reports are keep in the patients file both in the office where the report was requested and
where the report was conducted

PURPOSE
The medical records is indispensable from the point of view of the patient, the doctor , and the
hospital and for the medical education and research.

The Patient

 It serve to document the clinical history of the patient it's illness and course of the
disease.
 it serves to avoid omission or unnecessary repetition of diagnostic and treatment
measures.
 it assists in continuity of care in the event of future illness.
 Provides necessary information for insurance contributory health schemes or for the
employment purpose
Examples of Medical Records

Ancient-Records TB Clinical Records

Medical Records Release Form Medication Administration Record

Medical Check Medical Record Checklist

EHR System Medical Record

 LAYOUT OF MEDICAL RECORD OFFICE

REFERENCES
https://www.slideshare.net/VarugheseDaniel_1968/medical-records-department-
75785940?from_action=save

https://medicalcodingdegree.org/medical-records-history/

https://thelawdictionary.org/medical-records/

https://www.merriam-webster.com/medical/medical%20record

https://kidshealth.org/en/teens/medical-records.html

https://prezi.com/rlzjuh7llwao/different-types-of-medical-records/