10 Medical Record Components Important in a Medical Record Review
Medical records are the primary tool to support clinical-decision making and serves as evidence of policies in cases of litigation. They are both a medical and legal document which contain valuable patient data. It is comprised of identification information, medical history, clinical findings and billing details. As medical records contain sensitive patient data, medical professionals are obligated to secure these records in a confidential manner.
Why Medical Records Are Important
· Efficient patient care
Medical records are a documented basis for ensuring better care for the patients as theycontain detailed medical history, medications administered, diagnostic test results, pre- and post-operative care and progress of the patient.
· Helps to dispense medical negligence claims
They act as a guide forhealth practitioners andenable them to prove that thetreatment was provided correctly. Medical records are a reliable and authentic form of evidence that can be used to defend cases of medical negligence.
· Enables effective coordination between healthcare providers and the patients
Patients might seek treatments from health providers specializing in different fields. The required treatment strategy for the patient can be communicated with the network of healthcare providers efficiently with the help of medical records. This helps to have a better understanding about the effectiveness of treatment, medications and procedures.
· Serves as a legal document
Medical records are beneficial for both patients and physicians as these aid in reconstructing the entire episode of patient care. The medical chart can prove whether an event occurred or not and establish the standard of care provided. Attorneys use medical records to assess the case and to focus on its merits.
· Evaluation of claims by insurance companies
Medical records review is essential for insurance companies to determine the compensation for medical expenses in a personal injury case. These records are used for billing and reimbursement purposes. Also, with medical records, insurance companies can find discrepancies in claims furnished by their clients.
· For decision making
Quality care can be ensured by monitoring the medical records.
Components of Medical Records
Medical records are comprised of the same components irrespective of the format. They are maintained in three primary formats:
o Electronic
o Paper
o Hybrid
Medical records differ from person to person as patients have different volumes of medical information to be compiled. Also, the physicians’ notes differ largely with regard to prescription. The documentation of medical records depends upon the medical staffs who have compiled it. Whereas, there is uniformity in every completed medical recordwhen it comes to the components with which it is compiled. The components of the medical record are essential for understanding comprehensive details of the patient to ensure continuity of care.
1. Demography of patients
Patient information is collected during the registration process. It includes:
o Patient’s legal name
o Phone number and mail ID of the patient
o Address
o Ethnicity
o Gender
o Age
o Social security number for identification
o Employer name , address and phone number
o Name of the spouse and contact details for emergency purposes
Patient demographics play a major role in providing exceptional care. For example, health care professionals can identify the cause of an underlying condition based on the ethnicity of the patient. If the patient information is inaccurately captured, it can lead to increased claim denials and delayed payments. Erroneous collection of patient’s identity information creates inaccuracies in Population Health Analytics.
2. Financial information of the patient
o Name of the insurance payer
o Policy number
o Payment information of the person who is liable for the payments
o Mailing address for claims
o Name and contact details of primary as well as secondary payers
o Details of the Medicaid or Medicare card if the patient is seeking federal or state assistance.
3. Patient’s medical history
The detailed medical history of the patient helps physicians to conduct minutest analysis of the health of the patients. The details below are documented in medical history:
o Blood details
o Details about chronic conditions like diabetes, arthritis, asthma etc.
o Significant incidents that happened in the past and clinical findings of the same
o Vital signs that indicate the body’s basic functions
o Surgical and obstetric history
o Allergies and adverse reactions
o Developmental symptoms that need special attention
o Possible allergies due to certain medications
o Details about alcohol or drug abuse
o Immunization history
o Outcomes of physical examination
4. Family medical history
Certain diseases are caused due to genetic factors. Family medical history helps to identify patients at risk for diseases like stroke and type-2 diabetes. Family history is the most reliable indicator of the risk of developing these diseases. This helps physicians to take guided healthcare decisions.
5. Medications administered
It is essential to know the medicines ingested by the patients in the course of a treatment.This give an insight into possible complications of the medicines administered. Information such as the use of illegal substances is gathered during patient testimony.
6. Clinical observations and prescription of physicians
This denotes the findings and observations of the physician while assessing the health of the patient. It comprises the directions for the patient and also for the treatment team. The prescription notes of the physician have details about medications and medical supplies or equipment required by the patient for home use.
7. Diagnostic results
It includes the outcomes of diagnostic assays like blood tests, ECG, EEG or radiology testing. These results are important for error-free diagnosis of diseases.
8. Progress notes
These include alterations and addition of new information regarding the treatment of the patient. Progress notes specify the physical and mental condition of the patient, fluctuations in the patient’s vital signs, the frequency and volume of food intake, bowel functions etc.
9. Nursing notes
These are documentation comprising the patient’s health assessment, intervention and evaluation other than that of the physician.
10. Authorization forms
The patient’s health care information is highly confidential and it is the responsibility of the custodian of the medical records to secure this sensitive information. As per HIPAA privacy rules, the patient has the right to be informed about the privacy of personal information entered in the medical record as it is part of the Protected Health Information (PHI). A signed document from the patient regarding information that can be disclosed has to be obtained without violating the cardinal rules of HIPAA.
Medical records are a focal point for providing health care with utmost scientific quality. It is absolutely essential to have comprehensive details of the patient for effective medical record analysis.
