What is in the Medical Record?
Hospitals keep the most complete medical records. Hospitals must follow the guidelines of private accrediting organizations such as the Joint Commission on the Accreditation of Health Care Organizations , as well as standards set by the state and federal government. These guidelines specific the basic organization for the records so that records from different hospitals will be organized in the same way. This makes it possible for medical care providers to work in different facilities without having to learn a different system of records management for each facility. It also allows government and insurance auditors to review records and compare them between hospitals.
The medical record must include the tests that are ordered, their results, the orders for all drugs and treatments and the record that they were done, the nurses notes documenting the patient's condition at a regular basis, the physician's notes reviewing the patient's condition, the physicians instructions to the nurses, consent forms and other legal documents related to the patient's care, and the observations and orders of any other medical care providers seeing the patient. If the patient has surgery, there will be a note outlining the surgery and its outcome, and when the patient is discharged from the hospital, there will be a note documenting the patient's conditions and all the arrangements for follow-up care. The medical records are not stored in a single record but are distributed throughout the recordkeeping system of the hospital. The patient's medical chart is the physical record that stays with the patient, usually at the nurse's station, and has the day to day care records. The hospital pharmacy will records on the patient, as will the laboratory, and the results of tests such as x- rays and MRI scans will be stored in the laboratories that do the tests. There will be administrative records about the patient if the patient's care is reviewed by a hospital committee. The billing department will have its own records about the care that rendered and the billing for that care. Some of these records will on paper and others will be electronic. In time, most will be electronic.
A patient who stays in the hospital a few days with a serious illness may have a dozen people working on the primary medical chart and a dozen more working with records in other parts of the hospital. The record might be used 20 - 30 times a day. A patient in a large medical center hospital for a week for complicated care might have more than 100 people working with some aspect of a patient's record, and many of those people would use the record several times. Parts of the record may be sent to outside consultant physicians and to diagnostic laboratories if tests are ordered that cannot be performed in the hospital. The accounting department will prepare a detailed list of all the procedures, diagnoses, drugs, and devices used on the patient and send it to the insurer for payment. If the patient is suspected of having a communicable disease, the public health department will be notified and may investigate the patient's records, and if the patient is the victim of a gunshot or other potentially criminal injury, the police will be notified. Certain cancers and other epidemiologically significant diseases will be reported to state or national disease registries.
It is clear that even when this system works perfectly, patients only have a qualified right to privacy in their medical information. If everyone in the system is careful only to use the patient's information correctly and only to share with properly authorized persons, parts of the information may still be seen hundreds of people. More critically, most of those people need to see the information if the patient is to receive quality medical care. Increasing the protection of records and the paperwork necessary to use them can delay patient care and increased the cost of care. This system is not perfect, but given the millions of pieces medical information generated every day, there are very few improper uses or releases of patient medical information. Yet medical privacy is a major political issue because patients, advocacy groups, and even the U.S. Congress believes that patient privacy is being violated and that this must be stopped.