Healthcare organizations maintain medical records for several key purposes:
- Patient Care. Patient records provide the documented basis for planning patient care and treatment.
- Communication. Patient records are an important means by which physicians, nurses, and others communicate with one another about patient needs.
- Legal documentation. Patient records become legal records because they describe and document care and treatment.
- Billing and reimbursem*nt. Patient records provide the documentation patients and payers use to verify billed services.
- Research and quality management. Patient records are used in many facilities for research purposes and for monitoring the quality of care provided.
The content of Patient Records
Patient records list the following components as being common to most patient records:
Identification Sheet. Information found on the identification sheet originates at the time of registration or admission. It lists at least the patient name, address, telephone number, insurance carrier, and policy number, as well as the patient’s diagnoses and disposition at discharge.
Problem lists. It lists significant illness and operations the patient has experienced.
Medication record. It lists medicines prescribed for and subsequently administered to the patient.
History and physical. It describes any major illnesses and surgeries the patient has had, any significant family history of diseases, patient health habits, and current medications.
Progress notes. It should reflect the patient’s response to treatment along with the provider’s observations and plans for continued treatment.
Consultations. Its records opinions about patient’s condition made by a health care provider other than the attending physician.
Physician’s orders. It includes physician’s directions, instructions, or prescriptions given to other members of the healthcare team.
Imaging and X-ray reports. Interpreting images produced through X-ray, mammograms, ultrasounds, scans, and the like.
Laboratory reports. They contain the results of tests conducted on body fluids, cells, and tissues.
Consent and authorization forms. Are consents to admission, treatment, surgery, and release of information.
Operative report. It describes any surgery performed and list the names of surgeons and assistants.
Pathology report. It describes tissue removed during any surgical procedure and the diagnosis based on examination of that tissue.
Discharge summary. It summarizes the hospital stay, including the reason for admission, significant findings, from tests, procedures performed, therapies provided, responses to treatments, condition at discharge, and instructions for medications, activity, diet, and follow-up care.
