The Use of Medical Health Records

Medical Health Record is written collection of information about a patient’s health and treatment written by health care professionals. Doctor, nurses and other health care professionals write up medical/health records so that previous medical information is available when needed. A patient’s medical record should provide accurate information on: who the patient is and who provided health care; what, when, why and how services were provided; and the outcome of care and treatment. The medical record has four major sections: administrative, which includes demographic and socioeconomic data such as the name of the patient (identification), sex, date of birth, place of birth, patient’s permanent address, and medical record number; legal data including a signed consent for treatment by appointed doctors and authorization for the release of information; financial data relating to the payment of fees for medical services and hospital accommodation; and clinical data on the patient whether admitted to the hospital or treated as an outpatient or an emergency patient. Considering the composition of medical health record, there are four main uses of medical record. The main uses of the medical record are: to document the course of the patient's illness and treatment; to communicate between attending doctors and other health care professionals providing care to the patient; for the continuing care of the patient; for research of specific diseases and treatment; and the collection of health statistics.


Medical record has to be able to clearly document the course of patient’s illness and treatment reflecting that medical examination and procedure have been done. It is a must that as health care team we write what we do and we do what we write. Doing it will be good for medical health care team since evaluation of what have done to patients by looking at and redoing thinking of medical health record provides chance for improvement of health care team. Unwritten important things on medical treatment can be seen soon and prompt improvement can be done.


Medical record as means of communication between attending doctor and other medical health professionals providing care to the patient prevents misunderstanding and provides fast patient's status that will be useful for their consideration of making effective and efficient medical desicions. The doctor may need assistance from other medical health professionals such as health consultant, other health specialists, and nurses. Since they may be busy on their own tasks, spoken instruction or communication may not be enough. When cancellation is done, possibility on forgetting medical consuls or tasks may be forgotten. To overcome the forgetful situation, there should be reminder. In this case, written reminder--medical record-- will come in handy.


Medical record that is saved for several years is useful for continuing care of the patient. There may be some diseases or conditions that affect patient health condition further such as chronic diseases, potential relapse disease, allergy, and past medical treatment history. They must be considered while giving medical treatment to the patient because doing that will be considered as treating patient holistically. That is reasonable because we tend to be able to do proper, effective and efficient medical treatment to the patient if we get whole picture of patient health condition. Then, medical health team can concentrate more on continuing care of the patient without retreating uneffective past treatment.


Well documented medical records are also useful for research of disease, related treatment, and health statistics. Collecting them means collecting epidemiology data from population and this is valuable in the view of medical field of study. As ethical issues forbid medical health institutes to do intervensive procedure without evidence based medicine, data of patient continuing treatment and the result may provide basis on evidence based medicine without breaking the ethics. Then, possibility on researches of new medical intervensive procedure or method will be opened to improve the result of treatment.


In general, the use of medical health record brings good environment to development of medical health treatment. Adequate attention on proper making of medical health record ensures the optimal use of medical health record.
By. James (Dwi Notosusanto)