Section I: THE PHYSICAL RECORDS
MEDICAL RECORD DEFINED
A medical record is a document (military or civilian) that provides information on
patient evaluation, findings, diagnosis, and/or treatment.
: a document that outlines patient evaluation, findings,
diagnosis, and/or treatment.
THE PURPOSE OF A MEDICAL RECORD
a. Planning and Continuity of Treatment. The Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), a civilian organization that reviews
and accredits all military and civilian hospitals, defines the purpose of the medical
record. According to the JCAHO, the medical record is intended to serve as the basis
for planning patient care. The medical record provides for continuity in the evaluation of
the patient's condition and treatment. If a patient gets sick repeatedly, health care
providers can look back at what happened the last time and/or how the patient reacted
to medication. If a patient breaks his or her leg more than once, the first set of
radiographs can be compared to the second set.
b. Documentation. A medical record provides documentary evidence. It
describes the course of the patient's medical evaluation and treatment. It provides a
record of any changes in condition. (A change in condition might be profuse bleeding
from a laceration, which is subsequently stabilized upon stitching.) The medical record
reflects changes in a patient's condition that may occur in the hospital, as an outpatient
(ambulatory care), during an emergency hospital visit, or in a hospital administered
home care program. (Military hospitals do not commonly get involved in home care.
For long-term illnesses, home care is less costly than admission into a hospital facility.)
A civilian nurse providing home care would keep track of the patient's pulse, medication,
and so forth.
c. An Efficient Means of Communication for Health Care Providers. A
medical record documents communication between responsible practitioners and any
other health care professionals responsible for the patient's care. For example,
consider an x-ray technologist who takes radiographs and initials the number of films
taken. By making these entries, the radiographer is not only documenting his or her
actions, but also communicating with the physician. The physician does not have to
walk over and talk to the radiographer about every patient he or she sees. It would be
inefficient and time-consuming to do so. Thus, the record provides an efficient means
d. Protection of Legal Rights. The medical record is a legally valid source of
accurate information on the patient, the responsible practitioner, and the hospital. As
such, it can be used to protect the legal rights of the parties involved.