Which Of The Following Is Documented In A Rehabilitation Service Record?

Medical term

The terms medical record, wellness tape and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient'southward medical history and care across time within one particular health care provider's jurisdiction.^[1] A medical record includes a diverseness of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the assistants of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of wellness care providers and is generally enforced every bit a licensing or certification prerequisite.

The terms are used for the written (newspaper notes), physical (image films) and digital records that exist 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 evolution of personal wellness records (PHR) that are maintained by patients themselves, often on third-party websites.^[2] This concept is supported by US national health administration entities^[3] and past AHIMA, the American Wellness Information Management Association.^[4]

A medical tape folder being pulled from the records

Because many consider the data in medical records to be sensitive private information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such equally third-party access and appropriate storage and disposal.^[5] 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 asking.^[6]

Uses [edit]

The information contained in the medical record allows health care providers to make up one's mind the patient'south medical history and provide informed care. The medical record serves as the primal repository for planning patient care and documenting communication among patient and health intendance provider and professionals contributing to the patient's intendance. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.

The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.

Personal health records combine many of the above features with portability, thus assuasive a patient to share medical records beyond providers and health care systems.^[7]

Electronic medical records could also be studied to quantify disease burdens – such as the number of deaths from antimicrobial resistance^[eight] – or help identify causes of, factors of and contributors to diseases,^[9] ^[10] especially when combined with genome-wide association studies.^[11] ^[12] For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized^[13] forms to ensure patients' privacy is maintained.^[14] ^[12] ^[xv] ^[16]

Contents [edit]

A patient'south private medical record identifies the patient and contains information regarding the patient'southward 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.^[17] Further information varies with the individual medical history of the patient.

The contents are by and large written with other healthcare professionals in mind. This can result in confusion and hurt feelings when patients read these notes.^[eighteen] For example, some abbreviations, such as for shortness of breath, are like to the abbreviations for profanities, and taking "fourth dimension out" to follow a surgical condom protocol might be misunderstood as a disciplinary technique for children.^[18]

Media applied [edit]

Traditionally, medical records were written on paper and maintained in folders ofttimes divided into sections for each type of note (progress notation, society, exam results), with new data added to each department chronologically. Agile records are usually housed at the clinical site, merely older records are often archived offsite.

The advent of electronic medical records has not merely inverse the format of medical records only has increased accessibility of files. The employ of an individual dossier mode medical tape, where records are kept on each patient by name and disease type originated at the Mayo Clinic out of a want to simplify patient tracking and to let for medical inquiry.^[xix]

Maintenance of medical records requires security measures to forbid from unauthorized admission or tampering with the records.

Medical history [edit]

The medical history is a longitudinal record of what has happened to the patient since nascence. Information technology chronicles diseases, major and minor illnesses, as well every bit 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 electric current affliction state. It includes several subsets detailed below.

Surgical history: The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.
Obstetric history: The obstetric history lists prior pregnancies and their outcomes. It too 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 whatsoever medical allergies.
Family history: The family history lists the wellness condition of firsthand family unit members as well as their causes of death (if known).^[20] It may also list diseases mutual in the family unit or found only in ane sex or the other. It may also include a pedigree nautical chart. It is a valuable nugget in predicting some outcomes for the patient.
Social history: The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, and religious preparation. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the beliefs of the patient in relation to illness or loss. It may likewise give clues as to the cause of an illness (due east.1000. occupational exposure to asbestos).
Habits: Various habits which impact health, such as tobacco utilize, alcohol intake, do, and diet are chronicled, ofttimes as office of the social history. This department may also include more intimate details such as sexual habits and sexual orientation.
Immunization history: The history of vaccination is included. Any blood tests proving immunity will also be included in this section.
Growth nautical chart and developmental history: For children and teenagers, charts documenting growth as information technology compares to other children of the same age is included, so that health-care providers tin follow the child'due south growth over time. Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness. Additionally, a kid's behavior (such every bit timing of talking, walking, etc.) equally it compares to other children of the same age is documented within the medical tape for much the same reasons as growth.

Medical encounters [edit]

Within the medical record, private medical encounters are marked by discrete summations of a patient'due south medical history past a doctor, nurse practitioner, or medico assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation past a specialist ofttimes take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, even so, may take a shorter form such as the problem-oriented medical tape (POMR), which includes a problem list of diagnoses or a "SOAP" method of documentation for each visit. Each encounter will generally contain the aspects below:

Chief complaint: This is the principal problem (traditionally called a complaint) that has brought the patient to see the doc or other clinician. Information on the nature and duration of the problem will be explored.
History of the present illness: A detailed exploration of the symptoms the patient is experiencing that accept acquired the patient to seek medical attention.
Concrete exam: The physical examination is the recording of observations of the patient. This includes the vital signs, muscle power and test of the different organ systems, particularly ones that might direct be responsible for the symptoms the patient is experiencing.
Cess and plan: The assessment is a written summation of what are the most likely causes of the patient's electric current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).

Orders and prescriptions [edit]

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 [edit]

When a patient is hospitalized, daily updates are entered into the medical tape documenting clinical changes, new information, etc. These often take the course of a Lather note and are entered by all members of the wellness-intendance 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 [edit]

The results of testing, such equally blood tests (east.g., consummate blood count) radiology examinations (e.thou., X-rays), pathology (e.chiliad., biopsy results), or specialized testing (due east.g., pulmonary function testing) are included. Often, as in the case of X-rays, a written written report of the findings is included in lieu of the bodily film.

Other data [edit]

Many other items are variably kept inside the medical record. Digital images of the patient, flowsheets from operations/intensive intendance units, informed consent forms, EKG tracings, outputs from medical devices (such equally pacemakers), chemotherapy protocols, and numerous other important pieces of information form role of the record depending on the patient and his or her set of illnesses/treatments.

Administrative bug [edit]

A ward clerk in the Menn Hospital, Colorado

Medical records are legal documents that can exist used every bit evidence via a subpoena duces tecum,^[21] and are thus subject to the laws of the country/country in which they are produced. As such, there is nifty 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.^{[ citation needed ]}

In 2009, Congress authorized and funded legislation known as the Health It for Economic and Clinical Health Act^[22] to stimulate the conversion of newspaper medical records into electronic charts. While many hospitals and doctor'due south offices have since done this successfully, electronic wellness vendors' proprietary systems are sometimes incompatible.^[23]

Demographics [edit]

Demographics include patient information that is not medical in nature. It is often data to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information almost race and religion every bit well as workplace and type of occupation. Information technology as well contains information regarding the patient'southward wellness insurance. It is mutual to also find emergency contact information located in this section of the medical chart.

Production [edit]

In the The states, written records must be marked with the date and time and scribed with indelible pens without utilise of cosmetic paper. Errors in the record should be struck out with a single line (so that the initial entry remains legible) and initialed by the writer.^[21] Orders and notes must be signed past the writer. Electronic versions require an electronic signature.

Ownership of patient's record [edit]

Buying and keeping of patient's records varies from state to state.

US law and customs [edit]

In the United States, the information contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the tape^[24] per the Health Insurance Portability and Accountability Act.^[25] Patients take the correct to ensure that the information contained in their record is accurate, and can petition their health care provider to amend factually incorrect information in their records.^[21] ^[26]

There is no consensus regarding medical record ownership in the United States. Factors complicating questions of buying include the form and source of the information, custody of the information, contract rights, and variation in state law.^[27] In that location is no federal law regarding buying of medical records. HIPAA gives patients the right to access and amend their own records, only information technology has no language regarding buying of the records.^[28] Twenty-eight states and Washington, D.C., have no laws that ascertain ownership of medical records. Xx-one states have laws stating that the providers are the owners of the records. Simply 1 state, New Hampshire, has a law ascribing ownership of medical records to the patient.^[29]

Canadian law and community [edit]

Under Canadian federal law, the patient owns the information contained in a medical record, simply the healthcare provider owns the records themselves.^[30] The same is true for both nursing dwelling house and dental records. In cases where the provider is an employee of a clinic or hospital, it is the employer that has ownership of the records. By law, all providers must keep medical records for a period of 15 years beyond the final entry.^[31]

The precedent for the constabulary is the 1992 Canadian Supreme Court ruling in McInerney v MacDonald. In that ruling, an appeal past a physician, Dr. Elizabeth McInerney, challenging a patient's admission to their own medical record was denied. The patient, Margaret MacDonald, won a courtroom society granting her full access to her own medical tape.^[32] The case was complicated past the fact that the records were in electronic form and contained information supplied by other providers. McInerney maintained that she didn't have the right to release records she herself did not author. The courts ruled otherwise. Legislation followed, codifying into police the principles of the ruling. It is that legislation which deems providers the possessor of medical records, but requires that access to the records be granted to the patient themselves.^[33]

UK law and community [edit]

In the United Kingdom, buying of the NHS's medical records has in the past generally been described as belonging to the Secretarial assistant of State for Health^[34] and this is taken by some to hateful copyright also belongs to the authorities.^[35]

German law and community [edit]

In Germany, a relatively new law,^[36] which has been established in 2013, strengthens the rights of patients. It states, amongst other things, the statutory duty of medical personnel to certificate the handling of the patient in either hard copy or inside the electronic patient tape (EPR). This documentation must happen in a timely manner and embrace each and every class of treatment the patient receives, every bit well as other necessary data, such as the patient'southward case history, diagnoses, findings, treatment results, therapies and their effects, surgical interventions and their effects, also as informed consents. The information must include almost everything that is of functional importance for the actual, but also for hereafter treatment. This documentation must also include the medical report and must be archived past the attending physician for at least ten years. The law clearly states that these records are not only retentivity aids for the physicians, merely too should be kept for the patient and must be presented on request.

In add-on, an electronic health insurance card was issued in January 2014 which is applicable in Germany (Elektronische Gesundheitskarte or eGK), but also in the other member states of the European Union (European Health Insurance Card). Information technology contains information such equally: the proper name of the health insurance visitor, the validity catamenia of the menu, and personal data about the patient (name, engagement of birth, sex, address, health insurance number) as well data about the patient's insurance status and additional charges. Furthermore, information technology can contain medical data if agreed to past the patient. This data can include information concerning emergency intendance, prescriptions, an electronic medical record, and electronic physician's letters. However, due to the limited storage space (32kB), some information is deposited on servers.

Accessibility [edit]

United States [edit]

In the United states of america, 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 take the right to view the tape. The patient, however, may grant consent for whatever person or entity to evaluate the tape. The total rules regarding admission and security for medical records are set along nether the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations. A 2018 study found discrepancies in how major hospitals handle tape requests, with forms displaying limited information relative to telephone conversations.^[37]

Capacity: When a patient does not take chapters (is non legally able) to make decisions regarding his or her ain intendance, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians accept the ability to access the medical tape in lodge to make medical decisions on the patient's behalf. Those without capacity include the comatose, minors (unless emancipated), and patients with incapacitating psychiatric illness or intoxication.
Medical emergency: In the event of a medical emergency involving a non-communicative patient, consent to admission 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 direction audits, or program evaluation have admission to the medical record. They are non immune access to whatever identifying information, notwithstanding.
Adventure of death or damage: Information within the record can exist shared with authorities without permission when failure to exercise and then would issue in decease 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.eastward., information from illicit drug testing cannot exist used to bring charges of possession against a patient). This rule was established in the United States Supreme Courtroom case Jaffe 5. Redmond[1].

Canada [edit]

In the 1992 Canadian Supreme Court ruling in McInerney v. MacDonald gave patients the correct to copy and examine all information in their medical records, while the records themselves remained the property of the healthcare provider.^[32] The 2004 Personal Health Information Protection Human action (PHIPA) contains regulatory guidelines to protect the confidentiality of patient information for healthcare organizations acting as stewards of their medical records.^[38] Despite legal precedent for admission nationwide, there is still some variance in laws depending on the province. There is likewise some confusion among providers as to the telescopic of the patient information they take to give access to, but the linguistic communication in the supreme court ruling gives patient admission rights to their unabridged record.^[39]

United kingdom of great britain and northern ireland [edit]

In the United Kingdom, the Information Protection Acts and later the Liberty of Information Human action 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'southward wellbeing (due east.thousand., some psychiatric assessments). Also, the legislation gives patients the correct to check for whatever errors in their record and insist that amendments be fabricated if required.

Destruction [edit]

In general, entities in possession of medical records are required to maintain those records for a given menstruum. In the United Kingdom, medical records are required for the lifetime of a patient and legally for every bit long equally that complaint action can be brought. By and large in the United kingdom, any recorded information should be kept legally for 7 years, but for medical records boosted time must exist immune for whatsoever kid to reach the age of responsibility (20 years). Medical records are required many years after a patient's decease to investigate illnesses within a community (e.chiliad., industrial or environmental affliction or even deaths at the hands of doctors committing murders, as in the Harold Shipman case).^[40]

Abuses [edit]

The outsourcing of medical tape transcription and storage has the potential to violate patient–medico confidentiality by mayhap allowing unaccountable persons access to patient data. Falsification of a medical record by a medical professional is a felony in most United states of america jurisdictions. Governments accept often refused to disclose medical records of armed forces personnel who accept been used as experimental subjects.

Data breaches [edit]

Given the serial of medical information breaches and the lack of public trust, some countries take enacted laws requiring safeguards to be put in place to protect the security and confidentiality of medical information as it is shared electronically and to give patients some of import rights to monitor their medical records and receive notification for loss and unauthorized conquering of health information. The The states and the EU have imposed mandatory medical data breach notifications.^[41]

Patients' medical information tin be shared by a number of people both within the health care industry and across. The Wellness Insurance Portability and Accessibility Deed (HIPAA) is a United States federal constabulary pertaining to medical privacy that went into consequence in 2003. This constabulary established standards for patient privacy in all fifty states, including the right of patients to access to their own records. HIPAA provides some protection, but does non resolve the bug involving medical records privacy.^[42]

Medical and health care providers experienced 767 security breaches resulting in the compromised confidential health information of 23,625,933 patients during the menstruation of 2006–2012.^[43]

Privacy [edit]

The federal Wellness Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy past providing medical data handling guidelines.^[44] Non only is information technology jump by the Code of Ideals of its profession (in the example of doctors and nurses), just likewise by the legislation on data protection and criminal constabulary. Professional person secrecy applies to practitioners, psychologists, nursing, physiotherapists, occupational therapists, nursing administration, chiropodists, and administrative personnel, equally well equally auxiliary hospital staff. The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel. Still, the precepts of privacy must be observed in all fields of hospital life: privacy at the time of the behave of the anamnesis and concrete exploration, the privacy at the fourth dimension of the information to the relatives, the conversations betwixt healthcare providers in the corridors, maintenance of adequate patient data collection in infirmary nursing controls (planks, slates), telephone conversations, open up intercoms etc.

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External links [edit]

Personal Medical Records from MedlinePlus
American Health Information Direction Association
Medical Record Privacy - Electronic Privacy Information Center (EPIC)

Organizations dealing with medical records [edit]

ASTM Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by diverse EHR or Electronic Medical Record (EMR) systems, allowing easy interoperability between otherwise disparate entities.
American Health Information Management Association