English Assignment

MEDICAL RECORD &

MEDICAL HISTORY

BY :
Leader

: MUHAMAD JUPRIYANTO (15-121)

Secretary

: CLARESTA MARVA WILONA

Moderaror

: MITHA NOVI QUEENTYA (15-113)

Presenter

: NADILLA CHANIAGO

UNIVERSITAS BAITURRAHMAH
FAKULTAS KEDOKTERAN GIGI
2016

(15-112)

(15-120)

Member :

PUTRI AMALIA
(15-124)
ANANTA ILFIA RACHMI (15-122)
MITHA NOVI QUEENTYA (15-113)
YOGA HATRIOPAR
(15-115)
AZIRA IRAWANI EFFENDI (15-123)
KIKI ANORA
(15-126)
NIKE LASMUTIA
(15-114)
YELNI SUNDARI
(15-119)
IIN KURNIA AFIFA
(15-116)
MARLITA ANGGRAINI
(15-118)
ITA WAHYUNI
(15-125)
INTAN SYAHFUTRI
(15-106)
WIENA AVIOLITA SURI (15-107)
SITI MAYSAROH SITOMPUL
(15-108)
MOCH IKHWANUL MIRZA
(15-109)
SELVI HARVINA
(15-110)
LISA PEBRIANTI
(15-111)
FIKI ANNISA PUTRI
(15-117)

Introduction
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. The medical
record includes a variety of types of "notes" entered over time by health care professionals,
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 fundamental requirement of health care providers
and is generally enforced as a licensing or certification prerequisite.
The terms are used for both the physical folder that exists 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
records (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 information in medical records to be sensitive personal
information covered by expectations of privacy, many ethical and legal 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.

Definition
Medical Record is the collection of information concerning a patient and his or her
health care that is created and maintained in the regular course of business in accordance
with policies, made by a person who has knowledge of the acts, events, opinions or diagnoses
relating to the patient, and made at or around the time indicated in the documentation. The
medical record may include records maintained in an electronic medical/record system, e.g;
an electronic system framework that integrates data from multiple sources, captures data at
the point of care, and supports caregiver decision making.
The medical record excludes health records that are not official business records, such
as personal health records managed by the patient. Each Medical Record shall contain
sufficient, accurate 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. The information may be from any source and in any format, including, but not
limited to print medium, audio/visual recording, and/or electronic display.
The Medical Record may also be known as the Legal Medical Record or LMR
in that it serves as the documentation of the healthcare services provided to a patient by a
hospital, clinic, physician or provider and can be certified by the Record Custodian(s) as
such. The Legal Medical Record is a subset of the Designated Record Set and is the record
that will be released for legal proceedings or in response to a request to release patient
medical records. The Legal Medical Record can be certified as such in a court of law.

Purpose
The information contained in the medical record allows health care providers 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.
The traditional medical record for inpatient care can include admission notes, onservice notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative
notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
Personal health records combine many of the above features with portability, thus
allowing a patient to share medical records across providers and health care systems.
In addition, the individual medical record anonymised may serve as a document to
educate medical students/resident physicians, to provide data for internal hospital auditing
and quality assurance, and to provide data for medical research.

Policy/Procedures
Maintenance of the record

There are 5 procedures of maintenance of the medical record:

1

A Medical Record shall be maintained for every individual who is evaluated or treated
as an inpatient, outpatient, or emergency patient of a hospital, clinic, or physicians

office.
Currently, the Medical Record is considered a hybrid record, consisting of both
electronic and paper documentation.

Documentation that comprises the Medical

Record may physically exist in separate and multiple locations in both paper-based
3

and electronic formats.

The medical record contents can be maintained in either paper (hardcopy) or
electronic formats including digital images, and can include patient identifiable source
information, such as photographs, films, digital images, and fetal monitor strips

and/or a written or dictated summary or interpretation of findings.

The current electronic components of the Medical Record consist of patient
information from multiple Electronic Health Record source systems. The intent is to

integrate all electronic documents into a permanent electronic repository.

Original Medical Record documentation must be sent to the designated Medical
Records department or area. Whenever possible, the paper chart shall contain original
reports. Shadow files maintained by some clinics or care sites containcopies of
selected material, the originals of which are filed in the patients permanent Medical
Record.

Confidentiality

The Medical Record is confidential and is protected from unauthorized disclosure by

law. The circumstances under which may use and disclose confidential medical record
information is set forth in the Notice of Privacy Practices.

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 records 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 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 is a longitudinal record of what has happened to the patient since
birth. It chronicles diseases, major and minor illnesses, 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 states. It includes several subsets detailed below.
Surgical history: The surgical history is a chronicle of surgery performed for the patient. It
may have dates of operations, operative reports, and/or the detailed narrative of what the
surgeon did.
Obstetric history: The obstetric history lists prior pregnancies 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 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. 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, schooling and religious training. It is
helpful for the physician to know what sorts of community 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 use, alcohol intake, exercise,
and diet are chronicled, often as part of the social history. This section may also include more
intimate details such as sexual habits and sexual orientation.
Immunization history: The history of vaccination is included. Any blood tests proving
immunity 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 and 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" method of documentation
for each visit.
Chief complaint: This is the problem that has brought the patient to see the doctor.
Information on the nature and duration of the problem will be explored.
History of the present illness: A detailed exploration of the symptoms the patient is
experiencing that have caused the patient to seek medical attention.
Physical examination: The physical examination is the recording of observations of the
patient. This includes the vital signs, 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.

Accessibility
In the United States, 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 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
(HIPAA). The rules become more complicated in special situations.

Destruction
In general, entities in possession of medical records are required to maintain those
records for a given period. In the United Kingdom, 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 patients death to investigate illnesses
within a community.

Abuses
1

The outsourcing 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 in most United

States jurisdictions.
Governments have often refused to disclose medical records of military personnel
who have been used as experimental subjects.

Summary
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 Record
is the collection of information concerning a patient and his or her health care that is created
and maintained in the regular course of business in accordance with policies, made by a

person who has knowledge of the acts, events, opinions or diagnoses relating to the patient,
and made at or around the time indicated in the documentation.
The information contained in the medical record allows health care providers to
determine the patient's medical history and provide informed care. The Medical Record is
confidential and is protected from unauthorized disclosure by law. A patient's individual
medical record identifies the patient and contains information regarding the patient's case
history at a particular provider.
The advent of electronic medical records 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 out of a desire to simplify patient tracking and to allow for medical research.
In the United States, 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. In general, entities in possession of medical records are required
to maintain those records for a given period. In the United Kingdom, medical records are
required for the lifetime of a patient and legally for as long as that complaint action can be
brought.