Question

discuss the importance of protecting the medical record

Answer 1

Medical Record: it is a written document about the patient health regarding the patient’s identification data, history of past and present, diagnostic test, medication, surgery details, patients progress report.

       Traditionally, patient’s information has been written in charts by the health care provider and other health care services people. Due to advanced technology, the process of recording has been changed from the written information to the electronic typing and storing of information. Some of the organization follows written form of the information while others are following the electronic storing of the health information

Types of medical record:

1. Outpatient medical record: the patient has visited and consulted the physician in outpatient basis

2. In patient medical record: in which patient was admitted and received care. this types of record has identification information, history of the patient that includes family history , past and present medical history , socioeconomic history, person health history, physical assessment, laboratory investigation, medication, progress chart, types of cases such as medical legal case, sensitive information such as mental disorder, AIDS

3. written medical record: the information of the patient are documented in the charts

4. electronic health record: the information of the patient has been stored in digital fomat. other types of records are in the form CD, DVD such as coronory angiogram, imaging film such as Computed tomography, magnetic resonance imaging

Importance of protection of record

1. MEDICAL LEGAL CASES: This is the important record. Because hospital has to provide policy intimation to the nearest policy station 2. The hospital and health care provider has to provide wound certificate and discharge certificate on request of police in case of medico legal case, if the hospital and provider admitted the patient with the history of medico legal case.

2. TURNOVER: It is good witness in case of medical legal cases when staff turned over. The staff and health care provider may be turned over from the hospital. But it provides the information   regarding care received by the patient and staff and provider who provided care to the patient After analyzing the case sheet

3. CONFIDENTIALITY: Hospitals protect medical records. It helps the patient to reduce harm, and help the patient approach health care services and receives better care. Otherwise patient may file a case against hospital if any breach occurs. Patient has to right to privacy on his data.

4. RELATIONSHIP: it builds the relationship between the patient and patient. The patient receives on the basis of storing information safely. It provides continuity of care of the patient, there by patient receives satisfaction of achievement of care

5. PROOF: it provides of a proof of provided care to the patient. In any case medical injury or loss, the document provide witness to the law

6. SENSITIVE INFORMATION: the patient may be admitted with the sensitive case such as psychological case, child abuse, AIDS, patient get emotional and might have harmed if it is breached. So it is important for the hospital to protect the information

7. PRESERVATION: the document of the patient may be curious to everyone who actually is involved in the care of the patient. It is important to restrict other health worker to view patient information

8. Hackers: if the organization has low security features, chances to hack the information and misuse that information.Therefore the security measures to be implemented by the hospital to protect the information.

9. Continuity of care: it helps the patient to obtain information from the hospital once become adult when he was in child. Once he becomes adult, if he knows about his non confidential information, it may affect and tend disrupt care

10. Genetic information and surrogating: it is important document to be maintained by the hospital. There is a chance of passing of information of genetic information when it is passed through insurance and other procedures. It may harm the patient regarding use of the information. Surrogate and donor of eggs and sperms is confidential information. This details cannot be revealed out by the hospital in future otherwise it becomes legal issue

11. Research use: it help the research to use the records for the better quality care after obtaining permission from the patient

12. Statistical analysis: hospital should provide the details regarding the mortality and morbidity, number of cases identified newly, newly born