The term health record is also called a medical chart or medical record. These terms are used interchangeably to depict the orderly documentation of an individual patient's medical history and supervision across time within one specific health care provider's jurisdiction. A medical record comprises various types of remarks entered over time by healthcare specialists, reporting observations, administration of drugs and therapies, the order of administration, test results, diagnostic reports such as blood test reports, x-ray reports, etc. The proper maintenance of detailed and complete medical records is a vital requirement of healthcare providers and is generally required as a licensing prerequisite. These terms are specifically used for physical, written, and digital records that exist for each patient and the information found therein. 

Traditionally, the medical records of the patients were compiled and properly maintained by the health care providers. Now the advancement in online data management and storage has led to the development of personal health records (PHR). 

The health record can also be defined as the principal depot for the information and data about the healthcare services procured to each patient. It helps document the what, where, when, why, how, and who of the patient care. Data represents the basic facts about the people, procedures, measurements, textual descriptions, images, symbols, checklists, and statistics. Information is the data gathered, analyzed, and then transformed into a form that can be utilized for a distinct purpose. Information specifically represents meaning. Various names recognize health care in distinct healthcare settings.

Nevertheless, no matter what word is used, the primary function of the medical or health record is to report and aid patient care services. The vital purposes are related directly to the prerequisite of patient care services. The health record documents are the services provided by the clinical experts and allied health professionals working in various situations. They can be classified into various categories: patient care management, patient care support processes, financial, patient care delivery and other administrative processes, and patient self-management. Health record documentation assists and benefits nurses, physicians, and other clinical care professionals to make conscious decisions about diagnoses and treatments. It is also a tool for transmission or communication among the various caretakers. 

And the health record also represents formal evidence of the services received by the sole patient. 
Patient care management refers to all the activities relevant to managing the healthcare services offered to patients. The patient care support comprises the activities related to the healthcare organization's resources approach, the estimation of trends, and the communication of data among various clinical provinces. The medical record benefits the providers in analyzing different ailments, proposing practice guidelines, and assessing the quality of care. 

Health record data aspects are tended to help in controlling and documenting costs. The information in the health record infers the payment the provider will obtain in every type of reimbursement system. Patient self-management has become more actively involved in supervising their health and healthcare, therefore becoming a major health record user. 

Health records are the basis of clinical or medical coding. Medical coding is the process of interpreting significant medical information into simple codes to document health records and for medical billing. This definitive system of medical coding permits a more seamless transfer of the medical records and more productive analysis to trace the patients' health records. Even though the word "code" is in medical coding, medical coders do not write code for computer programming. They also do not uphold the medical or health records or have anything to do with assuring the safety and protection of the patient's data stored electronically. Medical coders are an impending part of the medical team.

Medical coders take the medical reports from doctors, comprising a patient's condition, the doctor's diagnosis, and prescription, which make up a vital part of the medical claim. The most crucial part of a medical coder's job is ensuring that all the billing and coding information is correct and accurate. 

People who work in the medical coding and billing sections of the health care organizations use software to keep track of patients' records. It would also help patients with payments. Medical coders keep the patient's healthcare records revised considering the patient's diagnosis and many other procedures. Medical coders specializing in coding and billing can work in hospitals or clinics and medical offices, insurance companies, and rehabilitation centers. The medical coders utilize electronic data to keep track of patient records, but some medical departments still use paper filing. Apart from the hospitals, medical coders can also build a good career in healthcare consultancy services. Also, law firms can hire a medical coder to investigate fraud claims. Also, the government agencies offer the opportunity to medical coders to work efficiently on projects that influence healthcare across the nation. 

Primary and Secondary Purposes of Health Record

  • Patient care delivery: Effective communication among the patient's different caregivers assures the continuity of patient services. The detailed information stored in health records permits healthcare providers to evaluate and manipulate risk.
  • Patient care management refers to all the activities related to controlling the healthcare services provided to patients. To analyze the illness severity, manage risk, perform quality assurance and provide the basis for utilization review. 
  • Patient care support processes: It involves all the handling of the activities. To assess workload and communicate information among departments. 
  • Financial and other administrative processes: The information will help determine the payment the provider will receive in every reimbursement system. To report costs, manage costs, and bill for services.
  • Patient self-management: The individual's active involvement in maintaining their own records as a primary user.
  • As per the Institute of Medicine education, regulation, research, and policymaking, all are considered under the secondary purposes of the health record. The secondary purpose or objective of the medical record is not related to specific clashes between healthcare professionals and patients. Instead, they are related to the domain in which the care is provided to the patient. 

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    Author's Bio: 

    Dr Santosh Guptha, CEO – MEDESUN is a dynamic leader in Healthcare Information Management, an expert in the field of coding analysis, EM auditing, and ICD-10-CM, ICD-10-AM Coding with a career span of more than a decade. He was instrumental in developing various ICD-10 coding tools, guides and has authored various ICD-10 training programs, blockchain technology in healthcare etc. Dr.Santosh Guptha has extensive knowledge in all areas of HIPAA, privacy and security, and the application of HIPAA requirements in physician’s offices and facilities settings.