The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single
patient
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health c ...
's
medical history
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...
and
care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by
healthcare professional
A health professional, healthcare professional, or healthcare worker (sometimes abbreviated HCW) is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician (suc ...
s, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of
personal health record
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. This stands in contrast to the more widely used electronic medical record, which is operated by ...
s (PHR) that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by
AHIMA, the American Health Information Management Association.
Because many consider the information in medical records to be sensitive private information covered by expectations of privacy, many
ethical
Ethics or moral philosophy is a branch of philosophy that "involves systematizing, defending, and recommending concepts of right and wrong behavior".''Internet Encyclopedia of Philosophy'' The field of ethics, along with aesthetics, concerns ma ...
and
legal
Law is a set of rules that are created and are enforceable by social or governmental institutions to regulate behavior,Robertson, ''Crimes against humanity'', 90. with its precise definition a matter of longstanding debate. It has been vario ...
issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.
Uses
The information contained in the medical record allows
health care providers
A health professional, healthcare professional, or healthcare worker (sometimes abbreviated HCW) is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician (suc ...
to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
The traditional medical record for inpatient care can include
admission note
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the i ...
s,
on-service notes,
progress notes (
SOAP note
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenti ...
s),
preoperative notes,
operative note An Operative report is a report written in a patient's medical record to document the details of a surgery. The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The information in the ope ...
s,
postoperative notes,
procedure note
Procedure may refer to:
* Medical procedure
* Instructions or recipes, a set of commands that show how to achieve some result, such as to prepare or make something
* Procedure (business), specifying parts of a business process
* Standard opera ...
s,
delivery notes,
postpartum notes, and
discharge note
Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremely ...
s.
Personal health record
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. This stands in contrast to the more widely used electronic medical record, which is operated by ...
s combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.
Electronic medical records could also be studied to quantify disease burdens – such as the number of deaths from
antimicrobial resistance
Antimicrobial resistance (AMR) occurs when microbes evolve mechanisms that protect them from the effects of antimicrobials. All classes of microbes can evolve resistance. Fungi evolve antifungal resistance. Viruses evolve antiviral resistance. ...
– or help identify causes of, factors of and contributors to diseases, especially when combined with
genome-wide association studies
In genomics, a genome-wide association study (GWA study, or GWAS), also known as whole genome association study (WGA study, or WGAS), is an observational study of a genome-wide set of genetic variants in different individuals to see if any varia ...
.
For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized forms to ensure patients' privacy is maintained.
Contents
A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further information varies with the individual medical history of the patient.
The contents are generally written with other healthcare professionals in mind. This can result in confusion and hurt feelings when patients read these notes.
For example, some abbreviations, such as for
shortness of breath
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...
, are similar to the abbreviations for profanities, and taking "time out" to follow
a surgical safety protocol might be misunderstood as
a disciplinary technique for children.
Media applied
Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.
The advent of
electronic medical record
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared throu ...
s has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the
Mayo Clinic
The Mayo Clinic () is a nonprofit American academic medical center focused on integrated health care, education, and research. It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staff, ...
out of a desire to simplify patient tracking and to allow for medical research.
Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.
Medical history
The
medical history
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...
is a
longitudinal
Longitudinal is a geometric term of location which may refer to:
* Longitude
** Line of longitude, also called a meridian
* Longitudinal engine, an internal combustion engine in which the crankshaft is oriented along the long axis of the vehicle, ...
record of what has happened to the patient since birth. It chronicles
disease
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
s, major and minor
illness
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that ar ...
es, as well as
growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease state. It includes several subsets detailed below.
;Surgical history
:The surgical history is a chronicle of
surgery
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
performed for the patient. It may have dates of operations,
operative reports, and/or the detailed narrative of what the
surgeon
In modern medicine, a surgeon is a medical professional who performs surgery. Although there are different traditions in different times and places, a modern surgeon usually is also a licensed physician or received the same medical training as ...
did.
;Obstetric history
:The
obstetric
Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgic ...
history lists prior
pregnancies
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but can ...
and their outcomes. It also includes any complications of these pregnancies.
;Medications and medical allergies
:The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies.
;Family history
:The
family
Family (from la, familia) is a Social group, group of people related either by consanguinity (by recognized birth) or Affinity (law), affinity (by marriage or other relationship). The purpose of the family is to maintain the well-being of its ...
history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a
pedigree chart
A pedigree chart is a diagram that shows the occurrence and appearance of phenotypes of a particular gene or organism and its ancestors from one generation to the next, most commonly humans, show dogs, and race horses.
Definition
The word pedigree ...
. It is a valuable asset in predicting some outcomes for the patient.
;Social history
:The social history is a chronicle of human interactions. It tells of the
relationships of the patient, his/her careers and trainings, and religious training. It is helpful for the physician to know what sorts of
community
A community is a social unit (a group of living things) with commonality such as place, norms, religion, values, customs, or identity. Communities may share a sense of place situated in a given geographical area (e.g. a country, village, tow ...
support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).
;Habits
:Various habits which impact health, such as
tobacco
Tobacco is the common name of several plants in the genus '' Nicotiana'' of the family Solanaceae, and the general term for any product prepared from the cured leaves of these plants. More than 70 species of tobacco are known, but the ...
use,
alcohol
Alcohol most commonly refers to:
* Alcohol (chemistry), an organic compound in which a hydroxyl group is bound to a carbon atom
* Alcohol (drug), an intoxicant found in alcoholic drinks
Alcohol may also refer to:
Chemicals
* Ethanol, one of sev ...
intake,
exercise
Exercise is a body activity that enhances or maintains physical fitness and overall health and wellness.
It is performed for various reasons, to aid growth and improve strength, develop muscles and the cardiovascular system, hone athletic ...
, and
diet
Diet may refer to:
Food
* Diet (nutrition), the sum of the food consumed by an organism or group
* Dieting, the deliberate selection of food to control body weight or nutrient intake
** Diet food, foods that aid in creating a diet for weight loss ...
are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and
sexual orientation
Sexual orientation is an enduring pattern of romantic or sexual attraction (or a combination of these) to persons of the opposite sex or gender, the same sex or gender, or to both sexes or more than one gender. These attractions are generall ...
.
;Immunization history
:The history of
vaccination
Vaccination is the administration of a vaccine to help the immune system develop immunity from a disease. Vaccines contain a microorganism or virus in a weakened, live or killed state, or proteins or toxins from the organism. In stimulating ...
is included. Any blood tests proving
immunity
Immunity may refer to:
Medicine
* Immunity (medical), resistance of an organism to infection or disease
* ''Immunity'' (journal), a scientific journal published by Cell Press
Biology
* Immune system
Engineering
* Radiofrequence immunity desc ...
will also be included in this section.
;Growth chart and developmental history
:For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.
Medical encounters
Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a
specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the ''problem-oriented medical record'' (POMR), which includes a problem list of diagnoses or a "
SOAP
Soap is a salt of a fatty acid used in a variety of cleansing and lubricating products. In a domestic setting, soaps are surfactants usually used for washing, bathing, and other types of housekeeping. In industrial settings, soaps are use ...
" method of documentation for each visit. Each encounter will generally contain the aspects below:
;
Chief complaint The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting pro ...
:This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor or other clinician. Information on the nature and duration of the problem will be explored.
;
History of the present illness
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting sympt ...
:A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
;Physical examination
:The
physical examination
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...
is the recording of observations of the patient. This includes the
vital signs
Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a ...
, muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.
;Assessment and plan
:The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).
Orders and prescriptions
Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.
Progress notes
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a
SOAP note
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenti ...
and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists,
respiratory therapist
A respiratory therapist is a specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people who have acute critical conditions, cardiac and pulmonary disease. Respirator ...
s, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health.
Test results
The results of testing, such as blood tests (e.g.,
complete blood count
A complete blood count (CBC), also known as a full blood count (FBC), is a set of medical laboratory tests that provide cytometry, information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cell ...
)
radiology
Radiology ( ) is the medical discipline that uses medical imaging to diagnose diseases and guide their treatment, within the bodies of humans and other animals. It began with radiography (which is why its name has a root referring to radiat ...
examinations (e.g.,
X-ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
s),
pathology
Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in ...
(e.g.,
biopsy
A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...
results), or specialized testing (e.g.,
pulmonary function testing
Pulmonary function testing (PFT) is a complete evaluation of the respiratory system including patient history, physical examinations, and tests of pulmonary function. The primary purpose of pulmonary function testing is to identify the severity ...
) are included. Often, as in the case of
X-ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
s, a written report of the
findings is included in lieu of the actual film.
Other information
Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/
intensive care unit
220px, Intensive care unit
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
s,
informed consent
Informed consent is a principle in medical ethics and medical law, that a patient must have sufficient information and understanding before making decisions about their medical care. Pertinent information may include risks and benefits of treatme ...
forms,
EKG
Electrocardiography is the process of producing an electrocardiogram (ECG or EKG), a recording of the heart's electrical activity. It is an electrogram of the heart which is a graph of voltage versus time of the electrical activity of the hear ...
tracings, outputs from medical devices (such as
pacemakers
An artificial cardiac pacemaker (or artificial pacemaker, so as not to be confused with the natural cardiac pacemaker) or pacemaker is a Implant (medicine), medical device that generates electrical impulses delivered by electrodes to the Heart ...
),
chemotherapy
Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemotherap ...
protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.
Administrative issues
![Ward clerk Menn Hospital La Junta CO (24648175876)](https://upload.wikimedia.org/wikipedia/commons/6/6f/Ward_clerk_Menn_Hospital_La_Junta_CO_%2824648175876%29.jpg)
Medical records are
legal document
Legal instrument is a law, legal term of art that is used for any formally executed written document that can be formally attributed to its author, records and formally expresses a legally enforceable act, process, or contractual duty, obligation ...
s that can be used as evidence via a
subpoena duces tecum
A ''subpoena duces tecum'' (pronounced in English ), or subpoena for production of evidence, is a court summons ordering the recipient to appear before the court and produce documents or other tangible evidence for use at a hearing or trial. In s ...
,
and are thus subject to the laws of the country/state in which they are produced. As such, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself.
In 2009, Congress authorized and funded legislation known as the
to stimulate the conversion of paper medical records into electronic charts. While many hospitals and doctor's offices have since done this successfully, electronic health vendors' proprietary systems are sometimes incompatible.
Demographics
Demographic
Demography () is the statistical study of populations, especially human beings.
Demographic analysis examines and measures the dimensions and dynamics of populations; it can cover whole societies or groups defined by criteria such as edu ...
s include patient information that is not medical in nature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information about
race
Race, RACE or "The Race" may refer to:
* Race (biology), an informal taxonomic classification within a species, generally within a sub-species
* Race (human categorization), classification of humans into groups based on physical traits, and/or s ...
and
religion
Religion is usually defined as a social- cultural system of designated behaviors and practices, morals, beliefs, worldviews, texts, sanctified places, prophecies, ethics, or organizations, that generally relates humanity to supernatural, ...
as well as workplace and type of
occupation
Occupation commonly refers to:
*Occupation (human activity), or job, one's role in society, often a regular activity performed for payment
*Occupation (protest), political demonstration by holding public or symbolic spaces
*Military occupation, th ...
. It also contains information regarding the patient's
health insurance
Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ...
. It is common to also find emergency contact information located in this section of the medical chart.
Production
In the
United States
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...
, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line (so that the initial entry remains legible) and initialed by the author.
Orders and notes must be signed by the author. Electronic versions require an
electronic signature
An electronic signature, or e-signature, is data that is logically associated with other data and which is used by the signatory to sign the associated data. This type of signature has the same legal standing as a handwritten signature as long as i ...
.
Ownership of patient's record
Ownership and keeping of patient's records varies from country to country.
US law and customs
In the
United States
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...
, 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
The Health Insurance Portability and Accountability Act of 1996 (HIPAA or the Kennedy– Kassebaum Act) is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1 ...
. Patients have the right to ensure that the information contained in their record is accurate, and can petition their health care provider to amend factually incorrect information in their records.
There is no consensus regarding medical record ownership in the
United States
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...
. Factors complicating questions of ownership include the form and source of the information, custody of the information, contract rights, and variation in state law. There is no federal law regarding ownership of medical records.
HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA or the Kennedy– Kassebaum Act) is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1 ...
gives patients the right to access and amend their own records, but it has no language regarding ownership of the records. Twenty-eight states and
Washington, D.C.
)
, image_skyline =
, image_caption = Clockwise from top left: the Washington Monument and Lincoln Memorial on the National Mall, United States Capitol, Logan Circle, Jefferson Memorial, White House, Adams Morgan, ...
, have no laws that define ownership of medical records. Twenty-one states have laws stating that the providers are the owners of the records. Only one state,
New Hampshire
New Hampshire is a U.S. state, state in the New England region of the northeastern United States. It is bordered by Massachusetts to the south, Vermont to the west, Maine and the Gulf of Maine to the east, and the Canadian province of Quebec t ...
, has a law ascribing ownership of medical records to the patient.
Canadian law and customs
Under
Canadian federal law, the patient owns the information contained in a medical record, but the healthcare provider owns the records themselves. The same is true for both nursing home and dental records. In cases where the provider is an employee of a clinic or hospital, it is the employer that has ownership of the records. By law, all providers must keep medical records for a period of 15 years beyond the last entry.
The precedent for the law is the 1992
Canadian Supreme Court
The Supreme Court of Canada (SCC; french: Cour suprême du Canada, CSC) is the highest court in the judicial system of Canada. It comprises nine justices, whose decisions are the ultimate application of Canadian law, and grants permission to b ...
ruling in McInerney v MacDonald. In that ruling, an appeal by a physician, Dr. Elizabeth McInerney, challenging a patient's access to their own medical record was denied. The patient, Margaret MacDonald, won a court order granting her full access to her own medical record.
The case was complicated by the fact that the records were in electronic form and contained information supplied by other providers. McInerney maintained that she didn't have the right to release records she herself did not author. The courts ruled otherwise. Legislation followed, codifying into law the principles of the ruling. It is that legislation which deems providers the owner of medical records, but requires that
access
Access may refer to:
Companies and organizations
* ACCESS (Australia), an Australian youth network
* Access (credit card), a former credit card in the United Kingdom
* Access Co., a Japanese software company
* Access Healthcare, an Indian BPO se ...
to the records be granted to the patient themselves.
UK law and customs
In the
United Kingdom
The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the continental mainland. It comprises England, Scotland, Wales and North ...
, ownership of the
NHS
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
's medical records has in the past generally been described as belonging to the Secretary of State for Health and this is taken by some to mean copyright also belongs to the authorities.
German law and customs
In Germany, a relatively new law, which has been established in 2013, strengthens the rights of patients. It states, amongst other things, the statutory duty of medical personnel to document the treatment of the patient in either hard copy or within the
electronic patient record
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared throu ...
(EPR). This documentation must happen in a timely manner and encompass each and every form of treatment the patient receives, as well as other necessary information, such as the patient's case history, diagnoses, findings, treatment results, therapies and their effects, surgical interventions and their effects, as well as informed consents. The information must include virtually everything that is of functional importance for the actual, but also for future treatment. This documentation must also include the medical report and must be archived by the attending physician for at least 10 years. The law clearly states that these records are not only memory aids for the physicians, but also should be kept for the patient and must be presented on request.
In addition, an electronic health insurance card was issued in January 2014 which is applicable in Germany (
Elektronische Gesundheitskarte or eGK), but also in the other member states of the European Union (
European Health Insurance Card
The European Health Insurance Card (EHIC) is issued free of charge and allows anyone who is insured by or covered by a statutory social security scheme of the EEA countries, Switzerland, and the United Kingdom to receive medical treatment in ...
). It contains data such as: the name of the health insurance company, the validity period of the card, and personal information about the patient (name, date of birth, sex, address, health insurance number) as well information about the patient's insurance status and additional charges. Furthermore, it can contain medical data if agreed to by the patient. This data can include information concerning emergency care, prescriptions, an electronic medical record, and electronic physician's letters. However, due to the limited storage space (32kB), some information is deposited on servers.
Accessibility
United States
In the
United States
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...
, the most basic rules governing access to a medical record dictate that 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
Consent occurs when one person voluntarily agrees to the proposal or desires of another. It is a term of common speech, with specific definitions as used in such fields as the law, medicine, research, and sexual relationships. Consent as und ...
for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under the guidelines of the
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act of 1996 (HIPAA or the Kennedy– Kassebaum Act) is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1 ...
(HIPAA).
The rules become more complicated in special situations. A 2018 study found discrepancies in how major hospitals handle record requests, with forms displaying limited information relative to phone conversations.
;Capacity
:When a patient does not have
capacity (is not legally able) to make decisions regarding his or her own care, a
legal guardian
A legal guardian is a person who has been appointed by a court or otherwise has the legal authority (and the corresponding duty) to make decisions relevant to the personal and property interests of another person who is deemed incompetent, call ...
is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the
coma
A coma is a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light, or sound, lacks a normal wake-sleep cycle and does not initiate voluntary actions. Coma patients exhi ...
tose, minors (unless
emancipated
Emancipation generally means to free a person from a previous restraint or legal disability. More broadly, it is also used for efforts to procure economic and social rights, political rights or equality, often for a specifically disenfranchis ...
), and patients with incapacitating
psychiatric
Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders. These include various maladaptations related to mood, behaviour, cognition, and perceptions. See glossary of psychiatry.
Initial psy ...
illness or
intoxication
Intoxication — or poisoning, especially by an alcoholic or narcotic substance — may refer to:
* Substance intoxication:
** Alcohol intoxication
** LSD intoxication
** Toxidrome
** Tobacco intoxication
** Cannabis intoxication
** Cocaine i ...
.
;Medical emergency
:In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been previously drafted (such as an
advance directive
An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no ...
)
;Research, auditing, and evaluation
:Individuals involved in medical research, financial or management
audit
An audit is an "independent examination of financial information of any entity, whether profit oriented or not, irrespective of its size or legal form when such an examination is conducted with a view to express an opinion thereon.” Auditing ...
s, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however.
;Risk of death or harm
:Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (i.e., information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the
United States Supreme Court
The Supreme Court of the United States (SCOTUS) is the highest court in the federal judiciary of the United States. It has ultimate appellate jurisdiction over all U.S. federal court cases, and over state court cases that involve a point o ...
case
Jaffe v. Redmond
Canada
In the 1992 Canadian Supreme Court ruling in McInerney v. MacDonald gave patients the right to copy and examine all information in their medical records, while the records themselves remained the property of the
healthcare provider
A health care provider is an individual health professional or a health facility organization licensed to provide health care medical diagnosis, diagnosis and therapy, treatment services including medication, surgery and medical devices. Health ca ...
.
The 2004
Personal Health Information Protection Act (PHIPA) contains regulatory guidelines to protect the confidentiality of patient information for healthcare organizations acting as stewards of their medical records. Despite legal precedent for access nationwide, there is still some variance in laws depending on the province. There is also some confusion among providers as to the scope of the patient information they have to give access to, but the language in the supreme court ruling gives patient access rights to their entire record.
United Kingdom
In the
United Kingdom
The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the continental mainland. It comprises England, Scotland, Wales and North ...
, the
Data Protection Acts and later the
Freedom of Information Act 2000
The Freedom of Information Act 2000 (c. 36) is an Act of the Parliament of the United Kingdom that creates a public "right of access" to information held by public authorities. It is the implementation of freedom of information legislation
...
gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g., information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's wellbeing (e.g., some psychiatric assessments). Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.
Destruction
In general, entities in possession of medical records are required to maintain those records for a given period. In the
United Kingdom
The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the continental mainland. It comprises England, Scotland, Wales and North ...
, medical records are required for the lifetime of a patient and legally for as long as that complaint action can be brought. Generally in the UK, any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patient's death to investigate illnesses within a community (e.g., industrial or environmental disease or even deaths at the hands of doctors committing murders, as in the
Harold Shipman
Harold Frederick Shipman (14 January 1946 – 13 January 2004), known by the public as Doctor Death and to acquaintances as Fred Shipman, was an English general practitioner and serial killer. He is considered to be one of the most prolif ...
case).
Abuses
The
outsourcing
Outsourcing is an agreement in which one company hires another company to be responsible for a planned or existing activity which otherwise is or could be carried out internally, i.e. in-house, and sometimes involves transferring employees and ...
of medical record transcription and storage has the potential to violate patient–physician confidentiality by possibly allowing unaccountable persons access to patient data.
Falsification of a medical record by a medical professional is a
felony
A felony is traditionally considered a crime of high seriousness, whereas a misdemeanor is regarded as less serious. The term "felony" originated from English common law (from the French medieval word "félonie") to describe an offense that resu ...
in most United States jurisdictions.
Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.
Data breaches
Given the series of medical
data breach
A data breach is a security violation, in which sensitive, protected or confidential data is copied, transmitted, viewed, stolen or used by an individual unauthorized to do so. Other terms are unintentional information disclosure, data leak, info ...
es and the lack of public trust, some countries have enacted laws requiring safeguards to be put in place to protect the security and confidentiality of medical information as it is shared electronically and to give patients some important rights to monitor their medical records and receive notification for loss and unauthorized acquisition of health information. The United States and the EU have imposed mandatory medical data breach notifications.
Patients' medical information can be shared by a number of people both within the health care industry and beyond. The Health Insurance Portability and Accessibility Act (HIPAA) is a United States federal law pertaining to
medical privacy
Medical privacy or health privacy is the practice of maintaining the security and confidentiality of patient records. It involves both the conversational discretion of health care providers and the security of medical records. The terms can also r ...
that went into effect in 2003. This law established standards for patient privacy in all 50 states, including the right of patients to access to their own records. HIPAA provides some protection, but does not resolve the issues involving medical records privacy.
Medical and health care providers experienced 767 security breaches resulting in the compromised confidential health information of 23,625,933 patients during the period of 2006–2012.
Privacy
The federal Health Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy by providing medical information handling guidelines.
Health and Human Services HIPAA Privacy Rule for health information.
/ref> Not only is it bound by the Code of Ethics of its profession (in the case of doctors and nurses), but also by the legislation on data protection and criminal law. Professional secrecy applies to practitioners, psychologists, nursing, physiotherapists, occupational therapists, nursing assistants, chiropodists, and administrative personnel, as well as auxiliary hospital staff. The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel. However, the precepts of privacy must be observed in all fields of hospital life: privacy at the time of the conduct of the anamnesis and physical exploration, the privacy at the time of the information to the relatives, the conversations between healthcare providers in the corridors, maintenance of adequate patient data collection in hospital nursing controls (planks, slates), telephone conversations, open intercoms etc.
See also
* Bioethics
Bioethics is both a field of study and professional practice, interested in ethical issues related to health (primarily focused on the human, but also increasingly includes animal ethics), including those emerging from advances in biology, med ...
* Electronic health record
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared throu ...
* Hospital information system
A hospital information system (HIS) is an element of health informatics that focuses mainly on the administrational needs of hospitals. In many implementations, a HIS is a comprehensive, integrated information system designed to manage all the asp ...
* Medical history
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...
* Medical law
Medical law is the branch of law which concerns the prerogatives and responsibilities of medical professionals and the rights of the patient. It should not be confused with medical jurisprudence, which is a branch of medicine, rather than a bra ...
* OpenNotes
OpenNotes is a research initiative and international movement located at Beth Israel Deaconess Medical Center (affiliated with Harvard Medical School).
OpenNotes organization
OpenNotes is a research initiative and international movement located ...
* Patient record access
Patient record access in the United Kingdom has developed most fully in respect of the GP record, because computerisation in that field is almost universal. British hospitals were slower to move into electronic records. From 1 April 2015 all GP pra ...
* Right to know
Right to know is a human right enshrined in law in several countries. UNESCO defines it as the right for people to "participate in an informed way in decisions that affect them, while also holding governments and others accountable". It pursues ...
* Physical examination
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...
* Physician-patient privilege
* Labour inspection The ''Inspection du travail'' (IT, ''Labour inspection'') is a French specialized body of civil servants, charged of the surveillance of employment and labour law in firms, created in 1892 during the Third Republic.
History
The Labour inspect ...
* Midwife
A midwife is a health professional who cares for mothers and newborns around childbirth, a specialization known as midwifery.
The education and training for a midwife concentrates extensively on the care of women throughout their lifespan; co ...
* Nursing
Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health ...
* Pharmaceutical
A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy (pharmacotherapy) is an important part of the medical field and re ...
References
External links
Personal Medical Records
from MedlinePlus
MedlinePlus is an online information service produced by the United States National Library of Medicine. The service provides curated consumer health information in English and Spanish with select content in additional languages.
The site brings t ...
American Health Information Management Association
Medical Record Privacy
- Electronic Privacy Information Center
Electronic Privacy Information Center (EPIC) is an independent nonprofit research center in Washington, D.C. EPIC's mission is to focus public attention on emerging privacy and related human rights issues. EPIC works to protect privacy, freedom o ...
(EPIC)
Organizations dealing with medical records
*ASTM
ASTM International, formerly known as American Society for Testing and Materials, is an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, an ...
Continuity of Care Record
Continuity of Care Record (CCR) is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of ...
- a patient health summary standard based upon XML
Extensible Markup Language (XML) is a markup language and file format for storing, transmitting, and reconstructing arbitrary data. It defines a set of rules for encoding documents in a format that is both human-readable and machine-readable. T ...
, the CCR can be created, read and interpreted by various EHR or Electronic Medical Record
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared throu ...
(EMR) systems, allowing easy interoperability between otherwise disparate entities.
American Health Information Management Association
{{DEFAULTSORT:Medical Record
Health informatics
Public records