Medical Records

Medical records

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Medical records

The medical record is the information of the patients regarding the case history at a specific health organization or clinic. Information includes health test results, family health history, past treatments, personal information, lifestyle information, and prescribed medications ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"B6geOxzf","properties":{"formattedCitation":"(AHIMA, 2011)","plainCitation":"(AHIMA, 2011)","noteIndex":0},"citationItems":[{"id":944,"uris":["http://zotero.org/users/local/mlRB1JqV/items/RH6QECIX"],"uri":["http://zotero.org/users/local/mlRB1JqV/items/RH6QECIX"],"itemData":{"id":944,"type":"article-journal","title":"Fundamentals of the Legal Health Record and Designated Record Set","container-title":"Fundamentals of the Legal Health Record and Designated Record Set / AHIMA, American Health Information Management Association","source":"library.ahima.org","abstract":",","URL":"http://library.ahima.org/doc?oid=104008","note":"PMID: 104008","language":"en","author":[{"family":"AHIMA","given":""}],"issued":{"date-parts":[["2011",2,2]]},"accessed":{"date-parts":[["2019",7,18]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (AHIMA, 2011). The medical record is used for several purposes which are classified into two categories that are primary purpose and secondary purpose.

Compare and contrast:

The primary purpose of the medical record refers to the provision of patient care. For instance, the health record helps the physician to understand the changes in the health of the patient through different preventions and medications. It, therefore, is useful to improve the health standard of the patient. On the other hand, the same health record can be used as a secondary purpose that is to educate the students. Medical records are used as the case study in different academic course for learning purpose about a certain illness or medication.

Health record as a primary purpose is used for communication between the patient and the health providers. For instance, personal information like name, contact number, age, and check-up details are recorded for subsequent episodes of care. Though the same record used as secondary purpose like the legal record of the patient. Whenever, patient case file against the health providers, the organization used this information for legal support.

Moreover, the primary purpose of the medical records includes billing verification, support to the patient, and analyze the basic facts about the patient's condition, measurement, treatment plans and prevention therapies. Whereas the secondary purpose of the medical record is for using it for research. Different researchers use the record to identify the disease risk factors, drug side effects, treatment effectiveness, useful intervention, genetic impacts, and clinical efficiency ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"UDVnUp91","properties":{"formattedCitation":"(\\uc0\\u8220{}Primary and Secondary Uses of Health Information,\\uc0\\u8221{} n.d.)","plainCitation":"(“Primary and Secondary Uses of Health Information,” n.d.)","noteIndex":0},"citationItems":[{"id":947,"uris":["http://zotero.org/users/local/mlRB1JqV/items/U6KRDLXR"],"uri":["http://zotero.org/users/local/mlRB1JqV/items/U6KRDLXR"],"itemData":{"id":947,"type":"webpage","title":"Primary and Secondary Uses of Health Information","URL":"http://www.healthinfoprivacybc.ca/health-information-disclosure/primary-and-secondary-uses-of-health-information","accessed":{"date-parts":[["2019",7,18]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (“Primary and Secondary Uses of Health Information,” n.d.). The bottom line is that both primary and secondary purpose for health records play a significant role in the quality improvement in healthcare.

References

ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY AHIMA. (2011). Fundamentals of the Legal Health Record and Designated Record Set. Fundamentals of the Legal Health Record and Designated Record Set / AHIMA, American Health Information Management Association. Retrieved from http://library.ahima.org/doc?oid=104008

Primary and Secondary Uses of Health Information. (n.d.). Retrieved July 18, 2019, from http://www.healthinfoprivacybc.ca/health-information-disclosure/primary-and-secondary-uses-of-health-information