medical record

5 Essential Components Of A Medical Record

No one can deny the importance of keeping a medical record of a patient in an organised fashion. Whether the patient is in a hospital for long term care or is a regular patient at a local clinic, it is crucial for the caregivers to have the requisite information.

Documentation of medical records makes it easy for medical professionals to access relevant information of patients. The two modes in which this documentation can be maintained are offline (that is the traditional, physical mode) or online.

Online documentation of medical records is being preferred these days due to the convenience that comes with it. When it comes to health insurance and medical information, patient privacy is of enormous importance and cannot be overlooked. Electronic Medical Records or EMRs help both small clinics and hospitals to be within the legal compliance requirements.


What is a Medical Record?

Essentially, a medical record contains information related to the health of the patient. It also contains relevant medical information. Now, the extent to which the information will be detailed or broad will depend on the clinic collecting the information as well as the patient’s consent.


Components of a Medical Record

As stated earlier, what exactly is contained in a medical record is often subjective and depends on the need and consent of the patient. However, there are certain basic components of a medical record that can be ascertained to be essential ones. We discuss some of them below.


1) Patient Identity – Patient identification is crucial in order to match the database to a subject. It is around this subject that all the information will revolve. Most likely, this subject is a combination of your name and one more differentiating piece of information.

This second piece of information can be your date of birth, address or social security number. Needless to mention, all this data is more secure when online medical records are used.


2) Patient’s Medical History – It is interesting to note that there are legal medical record standards. Any electronic medical record has to meet these standards. One of the essential components of a medical record is that particular patient’s medical history.In order to treat you better, the medical professional has to be aware of your medical past, whether you have any immune system disease, hypertension, diabetes, etc, whether you are allergic to any food item or medicine. All this information in a medical record helps the doctor treat you better.


3) Family History – Of course, when we talk about family history, we do not mean the names and details of your ancestors. We refer to their medical history. There are certain diseases which are hereditary in nature.


Some of the most common hereditary diseases are also the most dangerous. However, the good news is that if you are aware of any genetic predisposition to a particular disease, there are ways to mitigate the circumstances. It is here that family history as part of medical record makes a huge difference.

medical records

4) Treatment History – Did you know that many times, if you have been given a particular medication, you cannot be given the same medication before a certain time period is over? Further, if your treating physician is not informed about any recent or past surgeries that you had to get done, he may be making a mistake by prescribing you certain medication. A Medication checklist is also an important component of a Medical Record as it helps the physician or caregiver ensure that patients are taking the right medicines at the right doses and times and that there are no conflicts or adverse interactions between different medications.

A patient’s treatment history might not seem very interesting to the patient himself. Often, patients want to hide the past treatment, especially when they wish to take a second opinion. Nevertheless, it is an integral component of their medical record.


5) Patient Directions – Yes, we went there. We get it. You do not want to think or talk about death. But in very rare circumstances, you might be in a medical state when you are unfit to take a decision. In that case, do you want someone else to decide for you?

Even if you want others to decide, they may not want to take such a big decision. In these scenarios, a living will helps. Also, you may have a DNR (Do Not Resuscitate) directive for yourself. This is crucial information that must be on a medical record.

In the digital age, while people are willing to give away lots of personal information to their smartphone and internet providers, there is a skepticism when it comes to sharing private medical information. This is rightly so.

One of the ways to encourage more and more people to share requisite and correct information with their healthcare provider is to show them that their data is secure. Under HIPAA Privacy Rule also, a patient has the right to access and even amend their medical data.

As more and more people are made aware of the safeguards implemented for online medical records, surely adaptability will improve.