A medical record tells a story. Each section of the medical
record helps provide details of the story. Discuss why a medical record
is important and why those details are just as important. How could
the absence or disorganization of such details alter the story? Create a
“story” of your own where the inclusion or exclusion of specific forms,
documents, and information changed the course of the patient’s care.
Furthermore, discuss which filing method you would use and what you
would do with the file once it becomes “inactive.”
Expert Solution Preview
Introduction:
Medical records are important documents that tell the story of a patient’s health. It contains comprehensive information about the patient’s medical history, diagnosis, treatment, and progress. The details provided in the medical record are critical for the continuity of care, communication between healthcare professionals, and medical research. In this response, we will discuss the importance of medical records and the impact of missing or disorganized information. We will also create a hypothetical scenario to demonstrate the impact of different forms, documentation, and information on patient care. Lastly, we will discuss the filing method and what should be done with it once the record becomes inactive.
Answer:
Medical records are crucial in delivering optimal care to patients. The details documented in the medical record assist healthcare professionals in making informed decisions about diagnosing and treating patients. The medical record also provides a comprehensive healthcare history of the patient, which can aid in appropriately managing chronic illnesses and preventive care. Furthermore, medical records serve as legal documents in lawsuits and medical malpractices.
The absence or disorganization of specific details in the medical record could change the story significantly. For instance, if a relevant allergy is not listed in the record, it could lead healthcare professionals to prescribe medication that can cause an allergic reaction in the patient. Similarly, if medication or dosages are incorrect or unspecified, it can lead to adverse side effects or ineffective treatment.
To understand how different forms, documentation, and information can change patient care, consider the following hypothetical story. A patient visits a hospital with a severe headache, blurred vision, and neck pain. The physician suspects the patient had meningitis and ordered a lumbar puncture. The procedure results and the lab report is necessary for diagnosing meningitis. However, the lab report was missing, and the physician had to assume the diagnosis and start treatment immediately, which could be potentially harmful if the diagnosis is incorrect.
The filing method for medical records can vary, but the most common way is to use electronic medical records (EMR) or paper-based medical records (PBR). EMR warrants a fast and efficient way of recording, storing, and retrieving patient data. However, PBR can be labor-intensive and take up valuable office or storage space. Nonetheless, both filing methods should abide by the Health Insurance Portability and Accountability Act (HIPAA) guidelines, which requires a secure method to store patient information.
Once the medical record becomes inactive, it should be retained for a designated period then disposed of according to the HIPAA guidelines. The guidelines vary across different states, but they recommend retaining adult patient records for at least seven years and pediatric records for at least 21 years.
In conclusion, medical records play a crucial role in patient care and must be comprehensive and organized. The absence or disorganization of critical details in the medical record can impact patient care and potentially harm the patient. Additionally, the filing method of medical records must be secure and comply with HIPAA guidelines. Finally, once the medical record becomes inactive, disposing of it should be in compliance with the HIPAA guidelines.
