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Medical Record Documentation

Accurate medical records help to ensure proper care and prevent medical mistakes.

Medical Record Documentation

In an age when medical information and health histories can affect a person gaining employment or qualifying for medical insurance, as well as ensuring proper care and avoiding drug interactions, medical record documentation plays a large role in a patient's life. Understanding privacy in health information is being aware of the extent and content of medical record documentation.

What is Medical Record Documentation

Medical record documentation, according to the NYU Medical Center, encompasses all of the paper and electronic files and information referring to a person's personal health, both physical and mental. Any time a patient visits a doctor, succumbs to a medical test or fills a prescription, a record of the event is recorded. This information is stored chronologically in a readable, fully documented (dated with signatures) file under a patient's personal identifiers. Medical record documentation allows health care providers to do their job properly by providing them all the pertinent information necessary to make personalized health care decisions regarding their patients.

What Information is Contained Within Health Records

Every patient has different information in their files, as the content of medical records is specific to each individual. Medical records are accumulated over a lifetime of health care and hold much valuable information, both of an individual's health status as well as a large amount of biographical data.

Medical records may contain the following personal information:

  • Full name
  • Age
  • Date of birth
  • Address
  • Telephone number
  • Social security number
  • Medical history
  • List of current medications
  • Family information
  • Lifestyle information
  • Test results
  • X-rays
  • Surgical history
  • Medical insurance information
  • Genetic and blood test results indicating current and future health status

The patient does not have to visit their general practitioner to create a record. Any meeting with a nurse, medical doctor, mental health doctor, chiropractor, dentist or cosmetic surgeon (among a host of others) is recorded in the documentation of a patient's medical history.

Medical Records and Personal Privacy

In 2003, the Health Insurance Portability and Accountability Act (HIPAA) finally provided a standardized understanding of health records and privacy in America. HIPAA provides patients with privacy over all health records kept inside any medical or health facility that utilizes electronic databases. HIPAA does not cover health records kept or formulated outside of a medical or health facility or among providers that do not utilize electronic records. These locations may include the workplace, the federal government and medical insurance providers.

Requesting Medical Records

Once a year, MIB Group, Inc., an organization that deals with insurance fraud prevention, makes its files available to the public. An individual can request their own insurance file for no charge. The information contained within the MIB documentation is provided to medical insurance companies in both the United States and Canada. The records that the MIB holds are only pertinent to those patients who have applied for medical insurance in the preceding seven years before the date of the request.

To request a copy of all medical record documentation, the patient simply makes a written request in writing to their health care provider. As the Department of Health and Human Services explains, even if the health care provider posts a fee in connection with records, an inability or refusal to pay the fee does not prevent the individual from access to their records.

A parent is entitled to request both their own and their child's medical record documentation. If, after review, a patient finds a mistake in their medical records, they can request that a change be made. The health care provider is legally obligated under the HIPAA to address the request.

The Future of Medical Records

Electronic medical records (EMR) are growing in popularity as the digital age moves forward. Like any recording system, EMR has both positive and negative qualities for both the patient and the doctor. Often referred to as health information technology (HIT), the use of computers to store medical information comes with a variety of options. Sometimes, medical record documentation can be as simple as having a patient utilize a touch screen computer to fill out a health survey, but it could also include the filing of a patient's entire medical history on a database. The idea is that utilizing HIT resources will reduce the number of medical errors caused by misinterpretations of handwritten medical records. According to the U.S. Department of Health and Human Services, EMR could save the American health industry more than $160 billion every year. The downside of EMR is its potential for digital hacking, and, as of early 2009, there is no national health information plan to create records in a standardized form.

By taking the time to review and become familiar with the extent and content of medical record documentation, a patient can improve both the quality of their care and the quality of their health.

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