- The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
- The terms are used for the written (paper 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 development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association.
- Because many consider the information in medical records to be sensitive private information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. 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 request.
- Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.
- The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research.
- Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.
- The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as 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 current disease 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, an5
- Obstetric history
- The obstetric history lists prior pregnancies and their outcomes. It also 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 any medical allergies.
- Family history
- The family history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset 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 training. 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 behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).
- Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section 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 chart and developmental history
- For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.
d/or the detailed narrative of what the surgeon did.
Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (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 main problem (traditionally called a complaint) that has brought the patient to see the doctor 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 have caused the patient to seek medical attention.
- Physical examination
- The physical examination is the recording of observations of the patient. This includes the vital signs, muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.
- Assessment and plan
- The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).
Orders and prescriptions
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.
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care 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.
The results of testing, such as blood tests (e.g., complete blood count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., pulmonary function testing) are included. Often, as in the case of X-rays, a written report of the findings is included in lieu of the actual film.