Medical Records | NCH Healthcare System (2024)

FAQs

What is the medical records system in healthcare? ›

An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, ...

IM 7.2 The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

Documentation communicates the what, why, and how of clinical care delivered to patients. These records allow other clinicians to understand the patient's history so they can continue to provide the best possible treatment for each individual.

Key points to remember. The unit numbering system provides a single record, which is a composite of all data gathered on a given patient. The straight numeric filing system has a greatest advantage in training personnel within a limited span of time.

Medical records are used to track events and transactions between patients and health care providers. They offer information on diagnoses, procedures, lab tests, and other services. Medical records help us measure and analyze trends in health care use, patient characteristics, and quality of care.

Good documentation promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. At the end of the day, that's what really matters. Good documentation is important to protect you the provider.

The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.

Medical records can be stored digitally as electronic health records (EHRs) or physically as paper documents. Typically, files you use regularly are more accessible as an EHR. Whereas, long-term or inactive records are best stored offsite in physical files.

One of the most important principles of good record keeping is to take comprehensive notes in the first place. In their ethical guidance, the General Medical Council lists several key pieces of information which must be included within a clinical report. These are: Relevant clinical findings.

Why is health record data important? ›

Personal health records ( PHR s) can help your patients better manage their care. Having important health information – such as immunization records, lab results, and screening due dates – in electronic form makes it easy for patients to update and share their records.

The EHR generates a complete record of a clinical patient encounter or episode of care and underpins care-related activities such as decisionmaking, quality management, and clinical reporting.

A personal health history (conditions, how they're being treated and how well they're controlled, as well as important past information such as surgeries, accidents and hospitalizations) Doctor visit summaries and notes. Hospital discharge summaries.

An EHR is an electronic system used and maintained by healthcare systems to collect and store patients' medical information. EHRs are used across clinical care and healthcare administration to capture a variety of medical information from individual patients over time, as well as to manage clinical workflows.

Federal law allows medical providers to destroy medical records after six years but some states require a longer retention period. If the medical records pertain to a child, you may be required to retain them for more than 10 years.

The ability to share complete information instantly is one of the main differences between an EMR and an EHR. An EMR captures information from a single care provider, which is only available to that one care provider. However, EHRs are designed to be used by multiple care providers and healthcare organizations.

Electronic medical record (EMR) systems, defined as "an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization," [1] have the potential to provide substantial benefits to physicians, ...

The term “Medical Records” implies clinician records for diagnosis and treatment, while the term “Health Records” more broadly denotes anything related to the general condition of the body.

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.