Lecturer Of Physical Therapy
Basic Science Department
At the end of the Lecture the student
should able to:-
a) Defined medical record.
b) Identify purposes of medical record.
c) Describe main uses of the medical record.
d) Explain medical record as source of information.
e) Illustrate characteristics of medical record.
Medical Records of the patients
Overview to Medical record:-
• Medical record documentation is required to record
pertinent facts, findings, and observations about
health history including past and present illnesses,
examinations, tests, treatments, and outcomes.
• Also the medical record documents the care of the
patient and is an important element contributing to
high quality care.
• Medical record is a powerful tool that allows the
treating physician to track the patient’s medical
history and identify problems or patterns that may
help determine the course of health care
Definition Of Medical Record:
Medical record defined as collection of information
concerning a patient and his or her health care that
is created and maintained in the regular course.
Or systematic documentation of information about
patient's past medical history and treatment.
Finally, medical record can be defined as an
instance or event of medical care.
Definition Of Medical Record:
Consist of information kept by doctors, health care centers,
community health clinics or local hospitals detailing what the
doctors or other members of the health care team know about
the medical condition and history of the patients.
The information is usually about medical examinations,
treatment or operations and should be recorded at the time of
the consultation or immediately afterwards (drugs, therapist
orders, test results , radiological and laboratory reports).
Who can document the Medical
report?
Physicians, nurse practitioners, nurses and
other members of the health care team may
make entries in the medical record.
Other terms are the same meaning
of medical record are as followed:-
• Medical report
• Patient chart
• Health record
• Medical chart
Purposes of the medical record:
Primary and Secondary Purposes
Primary : directly relate to patient care
(Clinical purposes).
Secondary: indirectly relate to patient care
(Non clinical purposes).
Primary purposes:
The Primary purpose is to support the continuous
patients medical care by documenting sufficient
information about:
• Diagnostic procedures
• Diagnoses
• Prognoses
• treatment
Primary purposes:
It supports excellent medical care by:
• Aiding in identification of the patient.
• It helps in generating an effective diagnostic and
treatment plan.
• Physical exam findings.
• Diagnostic procedures and tests to be performed.
• Records the doctors' differential diagnoses ideas.
• Documents patients responses to treatment.
• Supports continuity of care.
• It documents communication with the patients.
Secondary purposes:
• Serve as a formal (legal/financial) record.
Legal data: a signed consent for treatment by
appointed doctors and authorization for the
release of information
Financial data: the patient whether admitted to
the hospital or treated as an outpatient or an
emergency patient.
Secondary purposes:
• Provide data for studies and research (Administrative).
Administrative : demographic and socioeconomic data
such as the name of the patient (identification), sex, date of
birth, place of birth, patient’s permanent address, and
medical record number.
Help to provide information through report example:-
Mortality and morbidity rate.
Malnutrition index.
Infectious or communicable disease.
Population census Fertility rate.
The main uses of the medical
record are:
• To document the course of the patient's illness
and treatment.
• To communicate between attending doctors and
other health care professionals providing care to
the patient.
• For the continuing care of the patient.
• For research of specific diseases and treatment.
• The collection of health statistics.
Characteristics Of Medical Record:-
With documentation of medical records, particular
emphasis must be placed on the five factors that
improve the quality and usefulness of charted
information:-
1. Accuracy.
2. Relevancy.
3. Completeness.
4. Timeliness.
5. Confidentiality.
1- Accuracy:
• Each individual medical record MUST be correct.
• Information in the medical record is relied upon
for accuracy throughout the patient lifetime.
• Inaccuracies (either commission or omission)
lead to improper medical advice being provided in
error and may result in adverse healthcare
outcomes or in legal proceedings.
2- Relevance:-
• It is important that medical records contain only
information relevant to the patient’s healthcare.
• Inclusion of inappropriate and irrelevant
information could result in damaging legal action.
3- Completeness:-
• ALL documentation, including that from the
outpatient clinics, emergency, medical
laboratory and radiology departments of the
hospital must be included in medical record.
4- Timeliness:-
There are specific time requirements for
completion of the medical record:
• History and Physical – completed and signed
within 24 hours of admission.
• Post- Operative Note – written immediately
following surgery.
• Operative Note – dictated and signed within 24
hours of operation/procedure.
• Medical Record – must be completed within 7 days
of discharge or outpatient visit.
5- Confidentiality:-
• Medical records are confidential and protected by
authority of the Privacy.
• Don’t leave patient-identifiable information on your
computer screen or exposed in your work area.
• Don’t talk about patients or families in hallways,
elevators, or in other public places.
• Don’t release medical record information without
the patient’s consent.
