Medical Record Reference Guide
The History and Future of Patient Charts
History of Medical Records
At one time medical records were as simple as notes that were kept by physicians in their office. Many times the physician would be the only one who read those notes, and they would be brief and kept in a simple folder with the patient’s name on the outside of a folder. Certainly, there was no concern about who else may actually get obtain the record, how long the record should be maintained, or who may have the right to examine the record if necessary. Hospitals rarely kept records independently; physicians relied on their office notes to treat their patients while in the hospital, and physicians consulted with each other when necessary to treat an individual.
In 1928 the Associated for Record Librarians of North America was founded by the American College of Surgeons. They recognized the necessity of comprehensive and long-term medical records on individual patients to provide continuity of care by their family physicians as well as the surgeons and other physicians they may encounter in a hospital setting. Since that time medical records have undergone changes and improvements, and much care has been developed in providing the most complete and thorough system to be sure that each individual gets the same physical examinations and has the same general medical records on file. Much concern has also gone into the privacy and confidentiality of patients and their medical care and information.
What’s Inside
The purpose of a patient’s medical records today is that they provide a complete and comprehensive history and current assessment of a patient’s health. This aids in justifying treatment in a patient, providing support and information to any other physician who may treat a patient, and in assessing a patient’s progress. Many things are contained in a patient’s medical records, and these are standardized in many offices. First, there is always a family medical history that is taken by a nurse or medical assistant. This is important due to the fact that many illnesses and diseases can be hereditary and may give indications of risk factors in a patient. The nurse will also get a personal medical history from a patient. This would include all current symptoms and illnesses a patient may be experiencing as well as any diseases a patient has had in the past. The medical record will contain a list of medications that a patient is taking. This list will be maintained throughout the time that the individual continues to see the physician, so the list may change, but the previous medications will not disappear from the medical records. It is important for the physician and any other physician who may treat an individual to know what medications may have been tried in the past. Also, a list of allergies will be noted at the top of the medication list. Also in the medical records will be personal information regarding an individual’s name, address, phone numbers, insurance information, and whom the physician can contact in the case of an emergency. A living will may be contained in a medical record in the event that a patient becomes incapacitated and unable to speak about care.
A patient’s medical records will also contain laboratory data and diagnostic testing that had been done on a patient. Usually, the records will contain progress notes as well. The notes will contain conversations and telephone conversations that are held between the physician and the patient, the nurse, and the patient, and often between physicians regarding the patient. The notes will also contain the physical examinations that are done when the patient is in the doctor’s office. The standard for this physical examination is often followed by the acronym SOAP: subjective data, objective data, assessment, and plan. The subjective data will be what the physician learns subjectively from the patient regarding his symptoms and problem. The objective information consists principally of the physical examination and laboratory and diagnostic testing. The assessment may contain one diagnosis for the symptoms presented, or there may be more than one working diagnosis. The plan, naturally, is the course of action to solve the problem the patient has been experiencing. This may consist of further testing, medication, or simply follow up.