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Every patient's medical records are different some contain more information due to their medical history. If a patient has alot of problems and have been treated then their file would have more information . Certain records also contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology terms that any person in the medical field can read It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected..
The purpose of a medical record is for the health care provider to provide endless care to the individual patient. It serves a source for planning patient care and the services provided to that patient. Medical records begin from when the patient born. It contains diseases, illness and whatever the patient tells their physician about his or her past and present status. It also contains lab test results, medication that was ever prescribed. It also contains allergies, referrals ordered to other health care providers and plans for further care.
Medical patient history inlcude families history and the status of the family members death if known. It tells relationships of the patient, his or her career and schooling this helps the physician to know and explain behavior of a patient in relation to illness or loss. It contains different habbits such as smoking use , alcohol , diet and exercise. History of vaccination is included and blood test prooving immunity. If a patient is hospitalized there are daily updates that are entered in the medical record; it documents clinical changes and new information.
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"Medical Patient Records." 123HelpMe.com. 20 Aug 2019
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A patient can request a copy of their medical record if they ask their provider . However A provider can also reject access to their records if it contains information that can cause physical or mental harm to one's self . In cases like this the provider can provide information to a third party who can notify the patient. A provider can charge up to forty five cents per page inlcuding fees for any research , handling , postage and materials for providing copies of xrays. A provider cannot charge the patient if the patient need these files for social security claim or appeals. A provider must hold a patients record for seven years after the last treatment date and three years from a patients death these are regulations from the department of health. If a patient chooses to change providers they would ask their former provider to transfer the records to the new provider and the old provider should no longer have these records.
The advantages of electronically records is that they can be easily accessed when needed anywhere in the facility.They can be taken anywhere as well providing the physician has an internet connection; ofcourse proving a login name and password. They are less consuming and it decreases the use of paper records.