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Components of a Medical Record - Health Care Ethics II

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e. Data Source. The medical record is a useful source of data for continuing
education programs and research. For example, the number of cases of spinal
meningitis reported in 1949, the symptoms reported, and the treatment provided can be
determined by a quick review of the medical records. Of course, all names would have
to be deleted from information extracted from the medical records to protect the
patients' privacy.
3-3.
CHARACTERISTICS OF A MEDICAL RECORD
Since medical records serve so many important purposes, they have to
constitute a complete, accurate, and up-to-date record of the patient's history, condition,
and treatment. The health care provider may, at times, view the record-keeping aspect
of the job as a nuisance; so much paperwork that detracts from the main mission--that
of caring for the patient. But, medical records serve so many important functions that
they cannot be taken lightly by the health care provider who is charged with making
accurate and timely entries. One adverse consequence of faulty record-keeping relates
to insurance reimbursement. If a hospital or physician fails to maintain complete and
accurate medical records reflecting the treatment rendered, it may not be possible to
obtain third-party reimbursement under MEDICARE, MEDICAID, and private insurance
coverage.
3-4.
COMPONENTS OF A MEDICAL RECORD
a. Admissions Record. The first part of the medical record, the admissions
record, is compiled when the patient is first admitted to the hospital. The admissions
record includes the patient's name, age, reason for admission, and any other pertinent
information on the patient's history.
b. The Clinical Record. The second part of the medical record is the patient's
clinical or treatment record. It should provide a continuing history of the treatment
provided and the patient's physical history. The exact nature of the complaint (the
reason for which the patient sought care) should be specified. There should be a
temperature chart, an admitting diagnosis and a subsequent diagnosis. (A patient
admitted for one complaint, might be revealed to have an entirely different diagnosis
after further testing or he or she might undergo a change in condition.) Consultations
should be included in the clinical record. The military "Consultation Sheet" should
accompany the patient as part of the patient's medical record when he or she is referred
to such places as orthopedics. Medical notes, medications, laboratory results, and x-
ray readings are additional components of clinical record. Surgical or delivery (birth)
records are also an important feature of the record. These should include anesthesia
reports and/or operative procedures and findings. Nursing notes, which list blood
pressure, temperature, and so forth, are another feature of the record. One-page
summaries of everything that has happened for the whole of the patient's hospital stay
are yet another important component of the record. The conditions of the patient at the
time of discharge and/or autopsy findings, if any, are also part of the record.
MD0067
3-3



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