Comprehensive medical records are important for many reasons. Of course, they are needed for continuity of care for all patients. There are also legal reasons that records must be kept in case of a complaint or lawsuit. (An insurance provider can furnish information regarding the needs for medical documentation.) Medical professionals concerned about records include general practitioners, dentists, opticians, and hospitals. All of these have some particular needs. For example, dentists keep the casts made to aid in fitting various oral appliances.
The elements of health-related records usually are:
- notes taken by the physician regarding the individual patient. These can be handwritten or entered into a computer
- all treatments and procedures both recommended and completed
- hospital admission and discharge forms
- laboratory and other test repots
- letters written by, or to, outside physicians or other professionals
- video, photographs, images, and printouts produced by MRIs and other equipment
- notations of all medications, allergies
- the doctor’s use of proscribed treatments, injections, and medications
- documentation for chronic conditions
All documents need to be signed and dated, and they need to be legible. And they must be secure.
Legal and Health Service Requirements
In the UK all medical practices must adhere to National Health Service regulations. These require confidentiality, adequate security, and appropriate usage (e.g. for providing a standard of care). Regulations require that medical records must be available to patients. (The Data Protection Act requires that all requests for patient records must be met within 40 days.)
A summary care record is usually also maintained for all patients; this is used when emergency care is required quickly and without a primary physician.
Extensive NHS records are now being accessed to aid researchers in their investigative projects. In 2012 an online system—the Clinical Practice Research Datalink—was set up to help practitioners, hospitals, mental health clinics, and disease registries participate in government-sponsored studies.
Apart from Health Service requirements, most medical professionals maintain records of their patients and practice for their own obvious reasons. First, they want to keep track of all treatment, problems, medications, injections, etc. Most doctors maintain a file on each patient, which are undated for each patient visit. As the individual becomes a long-term patient the file often become unwieldy. The notes, forms, lab results, and specialist records accumulate all too rapidly. The practice may elect to remove older files from the active records, or even to have them scanned and maintained digitally.
One type of medical records services is copying. Hospitals and clinics especially need to release information requested by insurance firms, unemployment departments, private physicians, and others as soon as possible. Various service firms provide the staff and quality control to get this accomplished with as little disruption as possible. These copies can be paper, or the documents can be scanned to produce either pdf images or OCR text. These services are also available to any type of medical practice, relieving the office staff of the copying chore. The service staff will locate, copy, and mail the needed records.
Some practices may desire the range of services similar to those provided by document management services to any business. These would include organizing, packing, labeling, and storing older documents off-site.
Hopefully, everyone realizes that keeping track of all the aspects of their personal health history is really important. Online personal health records (PHR) are maintained by the individual patient. Microsoft has a service, HealthVault, which has been available in the U.S. since 2007, and the U.K. since 2010. HealthVault is intended to provide personal information on demand; the information is provided by the subscriber, and can be supplemented with downloads from various medical tests and devices. (Google Health was a similar system taken down in 2011.) Based on open-source software, a PDR service named Dossia is made available by some employers and health insurance providers. The World Medical Card, developed by a Norwegian firm, was originally just a card, but has evolved into an international web-based PHR that can be accessed through a PC or a mobile device. Access to this system requires a personal membership, and the subscriber maintains his own records. Some of these systems allow for drug interaction checking and patient-provider messaging.
Guest Author : Connie Williams is an information junkie who lives to provide knowledge to her readers and clients. She writes articles and blog posts on a variety of topics such as document scanning services. She has set up records procedures for several clients, and has been responsible for indexing, archive storage, and disposal of many types of documents, including medical records storage.