Question

Patients are allowed to access their medical records and can ask that certain information be added or excluded from their file. Providers who include their patients in their medical record keeping foster trust and respect with their patients. Discuss four purposes of medical records. Based on the four purposes you listed, what could cause a patient to lose trust in the medical clinic? How would you address the issue?

Answer 1

Clear and concise medical record documentaion is very important to providing patients with quality care,ensuring accurate and timly payment for the services furnished,mitigating malpractice risks,and helping healthcare providers evaluate and plan the treatment and maintain teh continuation of care.medical records contain valuble information.It gives details about the patient's history,the presenting problem and the tratment received.Medical record aid in the planning and evaluation of the patient treatment.It allows to create a permenent record for the patient's future care,builds a database to evaluate the effectiveness of treatment that may be useful for research and education.

The purposes of medical records are

• It provides a starting point for treating the patient.
• provides interoffice and intraoffice communication.
• Determine any patterns that surface to signal the provider of patient needs.
• Serve as a basis for legal information neccessary to protect providers ,staff and patients.
• provide clinical data for research.

Providers who include their patients in their medical record keeping foster trust and respect with therir patients.The informations in the medical records is always to be protected with important privacy and confidentiality.Patients can be allowed to acess their medical records ,and also request certain informations not to be add in their files.It is recommended that before any information is released from the medical records even if it is subopned,the patient be notified and written approval received.