The Purpose of a Medical Record
The primary purpose of a medical record, according to Medical News: “The Business of Healthcare, is to provide a complete and accurate description of the patient’s medical history. This includes medical conditions, diagnoses, the care, and treatment you provide, and results of such treatments. However, it can also be stated that there are five purposes of a Medical Records.”
According to the American Institute for Health Management, there are five purposes a Medical Record for several key reasons:
- Patient Care. A patient’s records provide the documented basis for planning patient care and treatment.
- Communication. A patient’s records are an important means by which physicians, nurses, and others communicate with one another about patient needs.
- Legal Documentation. A patient’s record becomes a legal document to that patient’s health and care.
- Billing and Reimbursement. A patient’s records provide documentation of what the patient has paid and what insurance has paid, and what services were rendered.
- Research and Quality Management. A patient’s records are used in many facilities for research purposes and for monitoring the quality of care
The Importance of a Medical Record
According to the National Library of Medicine:
“Medical records are used to track events and transactions between patients and health care providers. They offer information on diagnoses, procedures, labs tests and other services. Medical records help us measure and analyze trends in health care use, patient characteristics, and quality of care.” These records are also used by the legal community for litigation for accidents & injuries, medical malpractice, wrongful death along with other areas.
When all information is compiled, this forms a permanent account of a patient’s medical history. If the patient maintains their medical records, this should allow for a comprehensive report to allow your healthcare professional to provide you with the appropriate care.
According to the BridgeClinic, with the help of information technology, healthcare could become more cost-effective and facilitate improved patient outcomes.
- Safety can be increased
- Processes can be sped up
- Claims processing and reimbursement can be improved
- Effectiveness of therapies and treatments can be monitored and tracked
- With a growing amount of information, outcome predictions can be made
- From a legal point of few, liability is reduced as a result of increased oversight
- With IT, loss of information, errors and omissions can be significantly reduced
- Accurate documentation of initial assessments and progress improves quality assurance
- Methodical records of symptoms, diagnoses and treatments will greatly benefit the next healthcare professional involved and more importantly benefit the patient
Doctors, Nurses, and other healthcare providers are not the only ones that rely on a patient chart. Medical Billers and Coders also use a patients’ charts to generate medical claims. From there the information gathered is sent to insurance companies to collect for services rendered. Max Freedman, Contributing Writer from Business News Daily, states that without a comprehensive medical chart, it is virtually impossible for medical billers to effectively do their job.
