There are different types of medical records used in healthcare. In paper medical records, patient information is produced, stored, and accessed in paper format. Electronic health records are an automated version of a patient's medical history, maintained by the healthcare provider, that contains key administrative and clinical data, including demographics, problems, prescriptions, vital signs, medical history, and laboratory data. However, a hybrid health record utilizes multiple formats, where the information is scanned, paper, and electronic formats.
Data plays a crucial role in the healthcare industry. It is used to diagnose illnesses, provide long-term care, and monitor patients' progress. Accurate and updated information aids healthcare providers in understanding a patient's medical history, allergies, medications, laboratory results, and treatment plans. Moreover, when analyzed, it facilitates the development of more effective treatments and preventive measures.
There are various forms or templates in the health record that serve different purposes. They include admission or patient registration forms that collect patient demographics such as name, contact details, and insurance information. Medical history forms outline past illnesses, allergies, surgeries, family medical history, and medication. They help healthcare providers understand health status and possible risks. Consent forms obtain permission from patients for treatments, procedures, and sharing of medical information. Diagnostic reports contain test results that are interpreted to make a diagnosis and determine treatment. Medical administration records facilitate the accurate and safe administration of medication.
Despite serving similar functions, paper records differ from the templates and structure of an EHR. Paper records are handwritten or typed documents that are time-consuming, error-prone, and have limited accessibility. Conversely, EHRs are digital and offer structured data entry, automatic data capture, efficient storage, and quick retrieval. EHRs provide decision support, clinical reminders, and interoperability, consequently easing coordination, reducing duplication, and improving communication.
Health records should adhere to guidelines and regulations established by bodies such as The Joint Commission, state licensing bodies, and the Medicare Conditions of Participation. It ensures quality care, patient privacy, and data security. They set standards that regulate documentation practices, retention periods, and patient consent and necessitate the use of standardized terminologies. Following these guidelines ensures accurate, complete, and accessible health records that safeguard patient confidentiality and mitigate legal liability.
