Medical Records are the written, physical (image film) and digital documents that exist for each individual patient in a healthcare setting. They are the source of patient information that allows health care professionals to determine a patient’s medical history and make informed decisions about their treatment. They also serve as a record of communication among patients and between patients and health care providers.
A patient’s medical record is a comprehensive collection of information that identifies the person and includes everything from family history to allergies, medications and test results. It can help a physician understand the cause of a problem and make more accurate diagnoses. It may also give doctors insight into a patient’s lifestyle habits, such as diet, exercise and smoking, which can impact their health.
In addition to medical history, a medical record contains vitals such as temperature, heart rate and blood pressure, and may include a patient’s weight, height and body mass index (BMI). It also includes diagnostic imaging studies, lab work such as blood tests and urine samples, and other health care related testing such as CT scans, MRIs, bone density and mammograms. It may also include audiotapes and videotapes of a patient’s examination, as well as advance directives such as living wills.
Many medical institutions have implemented Electronic Medical Records systems (EMR) or EHR to organize and store all of this information electronically. This is more efficient than storing paper files and allows for easy transfer to other facilities. It also gives patients access to their medical records via the Internet for ease of scheduling appointments, requesting prescriptions and obtaining test results.
Whether or not a facility has an EMR, it is always wise for patients to keep copies of their medical records in the event they need to be transferred to another healthcare provider. They can be especially useful in the case of an emergency and can provide a comprehensive overview of your medical history. Make sure you keep track of your log-ins to any online health records programs, apps or websites you use and share the passwords with a trusted friend or family member in the event something happens to you. Keeping multiple copies of your medical records is also a good idea in case you need to retrieve them quickly or in the event of a natural disaster. Also consider asking your doctor if they recommend any specific apps or programs that can help you keep track of your medical records.