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| Medical Record | |
|---|---|
| Name | Medical Record |
| Caption | Example of patient charting and clinical documentation |
| Specialist | Florence Nightingale, Ignaz Semmelweis, William Osler |
| Purpose | Documentation of patient health information for clinical care, billing, research, and public health |
| Onset | Hippocratic Oath era to present |
Medical Record A medical record is a systematic compilation of an individual's health information created during encounters with healthcare providers such as Florence Nightingale-era hospitals, modern Mayo Clinic systems, and national health services like the National Health Service (England). It supports clinical decision-making, billing, quality measurement, research, and public health surveillance used by institutions including Johns Hopkins Hospital, Cleveland Clinic, World Health Organization, and Centers for Disease Control and Prevention. Records evolve across paper traditions like the Kaiser Permanente problem-oriented chart and digital transformations led by vendors such as Epic Systems and Cerner Corporation.
A medical record documents diagnoses, treatments, procedures, medications, laboratory tests, imaging results, and clinical notes generated by clinicians at organizations such as Massachusetts General Hospital, Guy's Hospital, Mount Sinai Hospital, and academic centers like Harvard Medical School. It functions as a legal document in jurisdictions under laws such as the Health Insurance Portability and Accountability Act of 1996 and regulatory regimes like Joint Commission accreditation. Records facilitate continuity of care across settings including outpatient clinics at Mayo Clinic Health System, inpatient wards at Johns Hopkins Hospital, emergency visits at Beth Israel Deaconess Medical Center, and long-term care in facilities overseen by agencies such as Centers for Medicare & Medicaid Services.
Core components mirror templates used by institutions like St. Thomas' Hospital and include identification, problem lists, medication lists, progress notes, operative reports, discharge summaries, pathology reports from laboratories like Mayo Clinic Laboratories, and imaging studies from centers such as Imperial College Healthcare NHS Trust. Formats vary: paper charts historically used in facilities like Charité – Universitätsmedizin Berlin; electronic health records (EHRs) from vendors including Epic Systems, Cerner Corporation, Allscripts; and interoperable data standards championed by organizations such as Health Level Seven International and initiatives like Fast Healthcare Interoperability Resources. Specialized records capture dental charts at American Dental Association affiliated clinics, mental health notes at institutions like Maudsley Hospital, and rehabilitation documentation at facilities such as Spaulding Rehabilitation Hospital.
Creation occurs at points of care in emergency departments like Mount Sinai Beth Israel Emergency Department, operating rooms at Guy's and St Thomas' NHS Foundation Trust, and clinics affiliated with universities such as Stanford Medicine. Clinicians including physicians trained at Johns Hopkins University School of Medicine, nurses from Guy's and St Thomas' School of Nursing, allied health professionals, and medical coders employed by companies like UnitedHealth Group contribute documentation. Maintenance involves versioning, audit trails, and retention policies enforced by regulators such as U.S. Department of Health and Human Services and accrediting bodies like The Joint Commission. Health information management professionals use classification systems like International Classification of Diseases and billing codes from Current Procedural Terminology maintained by organizations such as American Medical Association.
Medical records serve as admissible evidence in courts under laws influenced by precedents from cases in jurisdictions like United States Supreme Court decisions, and are subject to statutory frameworks such as Health Insurance Portability and Accountability Act of 1996 and the General Data Protection Regulation in the European Union. Ethical obligations originate from traditions represented by figures like Hippocrates and institutional review boards at universities such as Oxford University and Yale University, governing secondary uses for research overseen by agencies like National Institutes of Health and funding bodies such as Wellcome Trust.
Privacy safeguards are implemented through technical and administrative controls used by enterprises such as Google Health and Microsoft offerings, and guided by standards from National Institute of Standards and Technology. Security measures include encryption, role-based access similar to policies at Veterans Health Administration, audit logging, and breach notification obligations under laws enforced by bodies like Federal Trade Commission and national data protection authorities such as Information Commissioner's Office (UK). Cybersecurity threats from actors highlighted in reports by Interpol and Europol have driven incident response playbooks adopted by hospitals including Cleveland Clinic.
EHR adoption accelerated through incentive programs like the Health Information Technology for Economic and Clinical Health Act and national strategies instituted by ministries such as Australian Digital Health Agency and NHS Digital. Interoperability relies on standards promoted by Health Level Seven International, Fast Healthcare Interoperability Resources, terminologies like SNOMED CT, and national networks such as Carequality and CommonWell Health Alliance. Cross-border data exchange involves legal frameworks exemplified by the Privacy Shield negotiations and technical efforts by consortia including OpenEHR.
Patient access rights are articulated in statutes like the Health Insurance Portability and Accountability Act of 1996, regulations applied by authorities such as the European Data Protection Board, and institutional policies at hospitals including Mayo Clinic and clinics affiliated with Kaiser Permanente. Debates about ownership cited by scholars at Harvard Law School and Yale Law School distinguish custodianship by providers like NHS England from asserted patient control advocated by organizations such as Patient-Centered Outcomes Research Institute. Mechanisms for access include patient portals offered by vendors like Epic Systems and Cerner Corporation, data subject access requests under General Data Protection Regulation, and mediated release for research governed by ethics committees at institutions like Johns Hopkins University.
Category:Health records