A medical record contains important information about a patient’s health history, current conditions, treatments, and care plans. While medical records can vary slightly between healthcare providers, there are 3 key components that are typically included:
1. Patient Information
This includes basic demographic and contact information such as the patient’s:
- Full name
- Date of birth
- Gender
- Address
- Phone number
- Email address
- Social security number
- Marital status
- Emergency contacts
- Employment status and occupation
Having this patient information readily available helps ensure proper identification and coordination of care. It also allows healthcare providers to reach the patient and their emergency contacts when needed.
2. Medical History
The medical history provides an overview of the patient’s health conditions and concerns over time. Key elements of the medical history typically include:
- Past illnesses and chronic health problems
- Surgeries and hospitalizations
- Injuries and accidents
- Medications, supplements, and allergies
- Family medical history
- Birth history (for pediatric patients)
- Immunization status
- Ob/gyn history (for female patients)
- Health habits like diet, exercise, tobacco use
Reviewing the medical history gives healthcare teams insight into the patient’s overall health status and risk factors. It aids diagnosis and helps determine appropriate treatments and screening tests.
3. Encounter Notes
For each patient encounter or visit, detailed notes are added to the medical record. These notes document:
- Chief complaint or reason for the visit
- Relevant history and symptoms
- Physical exam findings
- Diagnostic test results
- Assessments and diagnosis
- Treatment plan
- Medications and interventions
- Follow-up instructions provided to the patient
- Updates to medical, family, and social history
Having comprehensive encounter notes is crucial for coordinating care between different healthcare providers. The notes provide critical information about progression of health issues and response to treatment over time.
Importance of Medical Records
Medical records are vital for providing high quality, consistent patient care. Some key benefits include:
- Continuity of care – Records allow seamless care coordination as patients transfer between various providers.
- Improved outcomes – Detailed histories help accurately diagnose conditions while encounter notes allow monitoring of treatments.
- Reduced errors – Complete records prevent adverse events such as inaccurate medications or missed test results.
- Informed decision making – Comprehensive information aids development of optimal care plans customized to the patient.
- Streamlined processes – Easy access to organized records improves workflow efficiency for healthcare teams.
- Legal documentation – Records provide documentation of what care was provided in potential legal or regulatory cases.
Components of a Comprehensive Medical Record
While patient demographics, medical history, and encounter notes make up the core pieces of any medical record, comprehensive records also include:
- Medication lists – These specify current and past prescriptions, over-the-counter drugs, supplements, and dosages.
- Problem lists – These provide summaries of active and resolved health conditions.
- Treatment plans – These outline interventions, therapies, and management steps for health issues.
- Preventive services – Dates and details of screenings, immunizations, and health counseling are noted.
- Growth charts – For pediatric records, these track development milestones and vital statistics.
- Test results – Diagnostic, pathology, laboratory, and imaging results are included.
- Correspondence – Referrals, discharge summaries, and faxes exchanged with other providers are added.
- Legal forms – Advance directives, authorizations, and consents are incorporated.
Medical Record Formats
Patient medical records can be maintained in either paper or electronic format. Here is an overview of the two formats:
Paper-Based Medical Records
- Kept in individual paper folders or charts
- May include handwritten physician notes
- Forms and documents can be physically added
- Charts are stored in physical filing rooms
- Records retrieved manually when patients arrive
Electronic Medical Records (EMRs)
- Digitized patient records stored electronically
- Physician notes and forms are entered and stored digitally
- New documents can be scanned or directly uploaded
- Records are stored securely on servers
- Remote, instant access from multiple sites
While both formats contain the same medical information, EMRs provide digital enhancements like efficient searching tools, data analytics, prescription links, and improved accessibility. However, paper records are still used in many smaller clinics and practices.
Ownership and Access to Medical Records
Medical records are the property of the healthcare provider or facility that generates them. However, patients have a right to access and obtain copies of their records. The Health Insurance Portability and Accountability Act (HIPAA) establishes rules around medical record access:
- Providers must allow patients to request access to inspect or obtain copies of their records.
- Requests must be accommodated within 30 days.
- Providers can charge reasonable fees for record copies.
- Patients can request amendments or changes to their records.
- Strict privacy and security standards govern record storage and sharing.
In addition to the patient, treating providers like doctors, nurses, therapists, and pharmacists may access the medical record. With patient consent, records can also be shared with insurance companies, school health services, worker’s compensation programs, and more. Records can also be used anonymously for public health reporting and research.
Table Comparing Paper and Electronic Medical Records
| Feature | Paper Medical Records | Electronic Medical Records |
|---|---|---|
| Storage format | Physical paper files and charts | Digitized records stored on servers |
| Chart components | Handwritten or printed documents and forms | Digital documents, forms, images, videos |
| Accessibility | Limited to one site | Remote access from multiple sites |
| Searching capabilities | Manual searching | Powerful digital search tools |
| Data analysis | Minimal analysis capabilities | Robust reporting and analytics |
| Prescription management | Handwritten or faxed scripts | Digitized e-prescribing |
| Privacy controls | User access protocols | Advanced user authentication and encryption |
| Backups | Photocopies or microfiche | Extensive digital backups |
Examples of Medical Record Entries
Medical records contain various types of detailed entries made by physicians, nurses, specialists, social workers, and other healthcare team members. Here are some examples:
Progress Note
33 yo female presents with 2 days of worsening shortness of breath, wheezing, and cough productive of yellow sputum. Symptoms started gradually but have progressed rapidly. She also notes nasal congestion, sore throat, and subjective fevers/chills.
On exam, temperature is 101 F, pulse 105, blood pressure 130/86, respiratory rate 22. Oxygen saturation is 90% on room air. Lung sounds reveal diffuse wheezing and crackles bilaterally. Heart is tachycardic but regular rhythm. Oral pharynx appears mildly erythematous.
Assessment is acute bronchitis versus walking pneumonia. Possible early viral illness triggering asthmatic flare versus bacterial superinfection. Will start treatment with bronchodilators, corticosteroids, and antibiotics. Oxygen administered and bloodwork drawn. Chest x-ray pending.
SOAP Note
S – Patient complains of intense, sharp lower back pain that began this morning. Rates pain as 8/10. Makes it difficult to stand up straight or walk.
O – Exam shows tenderness over lumbar spine. Limited range of motion in trunk due to pain. Negative straight leg raise test. Strength and sensation grossly intact.
A – Acute lumbar back strain likely from heavy lifting at work yesterday.
P – Prescribed naproxen 500 mg twice a day for back pain. Recommend rest, ice, compression, and elevation. Advised to avoid strenuous activity for next 2-3 days. Follow up if symptoms worsen or fail to improve with conservative measures.
Operative Note
Postoperative Diagnosis: Acute appendicitis
Operation: Laparoscopic appendectomy
Surgeon: Dr. S. Roberts
Assistant: Nurse J. Dorsey
Anesthesia: General endotracheal
Specimen: Appendix, 6 cm in length, grossly inflamed
EBL: 20 mL
Fluids: 1000 mL LR + Ancef 1 gm IV given
Findings: Omentum adherent to inflamed appendix. Appendix dissected using cautery. Base of appendix doubly ligated with Vicryl suture. Appendectomy performed with surgical stapler.
Drains: None
Complications: None
Key Takeaways
In summary, the key components of a comprehensive medical record typically include:
- Patient demographics – name, DOB, contacts, etc.
- Medical history – conditions, medications, procedures
- Encounter notes – reason for visit, exam and test findings, diagnosis, treatment plan
- Medication lists, problem lists, treatment plans
- Test results, images, correspondence
- Legal forms and authorizations
Medical records can be paper-based or electronic, but EMRs are becoming standard. While records are legally owned by healthcare providers, patients have a right to access their records and obtain copies. Comprehensive medical records promote coordinated, high quality care and are an essential component of our healthcare system.