Medical Records
Contents of the Medical Record
- Personal demographics
- Past health, family, and social history
- Patient's chief complaint
- Vital signs and anthropometric measurements
- Findings and laboratory and radiology reports
- Diagnosis
- Treatment prescribed and progress notes
- Condition at the time of treatment
Types of Health Records
- Electronic
- Multiple users can access the record simultaneously.
- Fewer errors.
- Paper
- Less efficient.
- Good for evidence of patient care but not as useful in other capacities.
Importance of Versatility
- It is important for medical assistants to be versatile and knowledgeable about both electronic and paper systems.
The Importance of Accurate Medical Records
- Help providers provide the best possible care to the patient.
- Important for continuity of care with other healthcare professionals.
- Offer legal protection to those who provide care to the patient.
- Provide statistical information that is helpful to researchers.
- Vital for financial reimbursement.
Ownership of the Health Record
- Provider or medical facility (the "maker") owns the health record.
- The patient has the right of access to information but does not own the physical record.
- The patient has the right to demand confidentiality.