What are Healthcare Records?

Health records are the personal details associated with one’s mental and physical health and the health care service provision that gives their health status. Health records are recorded either in handwritten notes or digital or electronic form. It is important to keep health records updated to know about the latest update about the individual's health.

What Contents are Included in the Health Record? 

Patient health records contain the following key components -

  • Identification Sheet
  • The identification sheet starts with the admission or registration of the patient. Following are the things included- the name of the patient, address, contact number, insurance carrier, and a policy number. The disposition and diagnosis of the patient at times of discharge is also mentioned.

  • Problem Lists 
  • This list out the illness that the patient is experiencing as well as operations that have taken place.

  • Medicine Record 
  • It describes the prescribed medication and medicine administration of the patient.

  • History and Current Medication
  • It lists out surgeries and major physical or mental illness that patients experience as well as family history of the disease, prescription of current medicine and health habits of the patient.

  • Progress Note 
  • This note shows the response of the patient to treatment and medication.

  • Consultation
  • It notes the health condition of patients and the opinions provided by healthcare providers.

  • Order of the Physician
  • Prescription, direction, and instructions of the physician are provided here that can be viewed by other team members of the healthcare team.

  • X-ray and Imaging Reports 
  • It includes mammogram, scans, x-ray, ultrasounds that produces interpreting images.

  • Laboratory Reports
  • These reports give the test results that have been conducted on tissues, body fluids, and body cells. 

    Purpose of Maintaining Health Records

  • Federal and State Laws
  • Health records must be kept and well maintained as per federal and state laws in special events of deaths, births, and diseases to be reported and informed to public health agencies. Written health /medical records result in compliance with these regulations and laws.

  • Importance to Researchers 
  • Researchers use data derived from health records to understand the patterns of diseases and use statistical analysis. They determine the requirement to develop health outreach programs in a new way, either globally or locally. Data obtained from medical records are useful to medical educators as they can introduce this information related to patients to their students, which helps to facilitate medical management disease initiation and also help in evaluating outcomes based on information present in the health record.

  • Documentation of billed treatment
  • Documentation of billed treatment is being reviewed through health records. Medical claims are billed to third-party payers and Medicare, so health records prevent fraudulent billing. Fraudulent billing witness severe criminal and civil penalties. Healthcare professionals are therefore obliged to comply with legal billing practices. Thus, healthcare organizations aim to review patients’ health records and validate claims before reimbursement. Health records are completely reviewed by fraud investigators who work for state or federal programs and insurance companies to detect cases of billing fraud before claims are processed to offer insurance benefits.

  • Research Efforts
  • Health records help provide information that will support research and further studies, such as creating new products, evaluating healthcare technology, completing clinical research, drug therapies, etc. Health records help determine if the result of patient care delivered was appropriate or not. Health records help evaluate whether the patient care delivered was given economically and was effective or not. Health records provide healthcare details that help in detection of possible risk factors for a specific population, the feasibility of financial record system, and helps to create databases and registries for patients for better patient care and future patient contact.

  • Continuity of Patient Care 
  • The health record contains details that provide the outcome and treatment of a patient by healthcare providers. The record of patients helps in effective communication that can be used as a tool to continue patient care for the present as well as future patient encounter.

  • Future Outreach
  • Healthcare organizations want to show their services and bring them to light in the competitive market. Thus, these organizations are using medical health records to plan for future outreach and explain their existing services and programs. Medical records help organizations point out their areas of strength and how to develop and improve their areas of weakness. The organizations get to know from the data analysis of these records about how much feasibility they need to bring in their services to be more successful.

    Functions of Health Records

    Healthcare providers maintain health records to manage data to reduce errors and improve efficiency. Health records help consolidate clinical information into a single interface to ensure simplicity for all healthcare providers to access patient information quickly and bring improvements in team collaboration. There are several capabilities and functions of health records needed to ensure high-quality patient care. They are-

  • Understanding the core function of health record systems
  • Maintaining health records has created ample capabilities and critical functions for healthcare units. These include-

  • Decision support
  • Result management
  • Patient support
  • Reporting and population health
  • Electronic connectivity and communication
  • Administrative processes reporting
  • Order management
  • Health information and data 
  • The functions of health records have been designed so that more improvements can be brought in disease management, patient care, efficiency, and team collaboration. Although more features have continued to add with the progress of time, these core health record functions always remain throughout.

  • Detailed Health Information and Data
  • The main function of medical records is to collect and organize patient records and clinical data effectively. It includes-

  • Lab results
  • Diagnosis
  • Patient’s medical history
  • Medication
  • X-ray images and radiology
  • Treatments
  • Allergies
  • Health records are processed, stored, and organized so that it becomes easy for health professionals to retrieve the day easily. While delivering patient care, healthcare providers can overview the health record system and get the patient information quickly before proceeding further.

  • Result Management
  • It is important to check while delivering care to a patient that they have current information related to the patient’s medical condition. The health record system is the perfect solution that allows healthcare professionals to access all test and laboratory results without any delay. As soon as new results related to the test come in, they are uploaded by professionals to the health record for future use. This is useful when another healthcare professional takes responsibility for the treatment. The healthcare team can easily access the latest details to continue the real-time medical treatment. The healthcare team takes help from these records to know about past treatment medical histories to ensure that no minute information related to the patient is being ignored or overlooked. Apart from result management, an additional core function of the health record is sharing test results with healthcare providers. Healthcare providers don’t mean a single individual since it includes many providers and practices working collaboratively to treat one patient. Health record helps in submitting information related to patients back and forth quickly for best results and collaboration.

  • Order Management
  • When you track orders for tests and prescriptions for many patients, it will be complicated for the healthcare team. An electronic health record system called the EHR system helps medical professionals easily enter and store orders for every patient to streamline the healthcare process and improve the level of workflows. So order management is another core function of health record that helps in the following ways –

  • Enhances execution speed 
  • Lowers duplication rate 
  • Improves legibility 
  • When the healthcare team enters all orders in one database, they tend to make lesser mistakes and offer effective patient care

  • Decision Support
  • The element of decision support combined with a great degree of knowledge is important in the field of the healthcare system to offer good quality patient care, greater extent of accuracy, reliability, and safety in the process of decision making. Evidence-based tools are used for health records that help healthcare teams plan and decide on the patient's treatment process. Health records perform the function of supporting the decision that allows medical care providers to ensure compliance with effective clinical practice by making them aware of the existing treatment methods and plans. Health records help patients get updates about their treatment plans and develop preventive methods.

  • Communication and Connectivity
  • To facilitate effective patient treatment, clear communication is necessary between patients and healthcare providers. Health records help in simplifying the process of treatment by facilitating quick communication and asking questions related to the treatment process.

  • Patient Support
  • Patients get the accessibility to support tools with the aid of health records that helps in engaging with the healing process and getting answers to all their question and concerns. Health records help to access details related to their medical care needs. All details and information kept or stored in health records or files are available to the healthcare providers 24*7.

  • Administrative Processes Reporting
  • Reporting the administrative process is a time-consuming yet important part of practice management. One important function of health records is to simplify and automate many healthcare administrative tasks so that doctors and nurses can spend their valuable time on patient care. Health records help in the administrative process by helping in the following ways-

  • Patient outreach
  • Scheduling
  • Billing
  • Time management
  • Storing all necessary information and administrative data in health records help in improving accuracy reliability and brings effective medical care delivery to make sure that there are no pitfalls.

  • Reporting and Population Health
  • Population health is greatly benefitted from information obtained from healthcare practice. Health records help healthcare settings, and clinics share data from clinics to public health entities, including CDS' Public Health Immunization Registry Or Centers for Disease Control and Prevention. The information obtained from health records helps nongovernment, and government entities track and monitor the population's overall health, control the spread of infectious disease or virus, and create and forecast immunization.

    Important considerations for keeping health records

    Health records have to be kept legibly, clearly, and accurately. Medical professionals should keep in mind the laws while recording medical events so that the information can be stored and recorded securely and safely. Following things should be recorded in a patient’s health record:

  • Name of patient and date for every new entry in the record 
  • Clinical findings that have some relevance
  • Decisions made by medical professionals based on the findings and the consequent action taken 
  • Prescribed drug details
  • Investigation or treatment details that have been carried out
  • Health records should contain all details about test results, scans, x-ray, surgery records, telephonic conversation notes with face-to-face appointments. 
  •  Importance of keeping health records

    Healthcare organizations maintain health records timely for the following reasons-

  • Patient care- Health records related to patients offers the documented basis for making effective patient treatment and care plan.
  • Communication- Nurses, doctors, and physicians take patients’ health records as an important means to discuss and communicate patient needs and requirements.
  • Legal documents- Patient health records are known as legal documentation because these records help in describing treatment plans and document patient care. 
  • Billing and reimbursing- Medical bill payers or patients use health records as a means of documentation to verify the bills. 
  • Research purpose and quality management- Research is facilitated through health records as well as quality management for monitoring treatment and quality care provided at a hospital setting.

    How do health records support the health of residents? 

    When health organizations maintain a history of patient care delivered to the residents, the staff members can monitor and evaluate the progress of these residents along with the efficiency of the treatment plan. For instance, healthcare professionals make digital charts to know the effectiveness of medication over a time period and improve patients' health conditions. They can also know about the positive or negative sides of the healthcare given from these health records. Healthcare professionals get a complete picture of the effectiveness of treatment and residents' recovery journey.

    All care establishment aims to keep the health of the patient as the main priority. So health records serve as a means to improve and access the present distributed care. Medical Coding Classes and CPC Training Hyderabad can help you understand the purpose and function of the health records.

    Author's Bio: 

    A postgraduate in Fashion Technology. Shalini is a writer at heart! Writing for her is an expression of her true self. After a short stint as a textile expert, she decided taking up writing full time. Shalini compiles content on myriad topics. A mother to a tiny tot, she uses her personal website and blog to explain the subtle yet perplexing aspects of parenting and motherhood. When she's not writing, she is either pursing her passion of exploring the latest tech innovations or crooning to her favorite music. Find out what she has to say about the trivial things we call "LIFE".