Question

What is the significance of the medical record for the physician? For the healthcare professional? For the patient

Who owns the medical chart?

Answer 1

Medical records are a combination of both self-reported patient information and a physician’s notes on diagnoses, care, and treatments. These histories involve a variety of information about a patient’s health history and personal habits. Medical records consist of a patient’s demographic information (name, address, age, gender, etc) as well as that patient’s medical history, test results, vaccinations, and other medical history. The need for continuity of care for the patient is the main reason to maintain medical records.

Health professionals and others are able to use adequate medical records to reconstruct the essential parts of each patient contact, without the need to refer to memory. When medical notes are sufficiently comprehensive, it is easier for health professionals to carry on where a colleague left off. Health professionals also find good medical records vital for defending a complaint or clinical negligence claim, given the insight that they provide into the clinical judgment that was exercised at the time. In general, if records are adequate enough for continuity of care, they will also suffice for legal use. They will be able to catch human error, track therapies, monitor effectiveness of treatments, and make predictions about outcomes throughout the entire course of a patient’s lifetime.

If a patient cannot remember or is unsure of their current medications, a maintained medical record can provide this information to a doctor, thus eliminating any potential drug interactions. Further, if a patient has a severe injury, is unresponsive or has an unclear illness, an examination of that patient’s medical records can help a medical professional respond with appropriate treatment.

In the United States, the data contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record per the Health Insurance Portability and Accountability Act. Only the patient and the health-care providers directly involved in delivering care have the right to view the record. The patient, however, may grant consent for any person or entity to evaluate the record. In canada, the patient owns the information contained in a medical record, but the healthcare provider owns the records themselves.