Medical Records
What are medical records? Legal documents Management of patient care Alert healthcare providers to changes in patient conditions Provide clinical data for research Documents belong to healthcare provider Medical information belongs to patient Governed by HIPAA guidelines May be paper, electronic, or combination of both
Types/format Inpatient: Hospital, rehabilitation facility, nursing home Admission demographics Admission assessment Physician’s orders History and physical Intake/output; vital signs Medication administration records Progress notes Multidisciplinary team notes Nurses notes/flow sheets Transfer forms Lab, radiological reports Billing information
Types/format Outpatient Physician’s practice Clinic History and physical Lab/radiological reports Physician’s orders Vitals signs flow sheet Physician’s progress notes
Admission Physician must authorize; RN has primary responsibility Assistive personnel help as directed Identify patient Customer service important to patient and family; provide comfort and reassurance Admission assessment; specimen collection, document medications from home, equipment or prosthesis from home, valuables History and physical Physician’s orders Lab/radiological reports Physician and multidisciplinary team notes
Transfer To another unit or hospital (discharge); usually dependent upon patient condition transfer form including assessment If patient to be transferred to another facility; pack all belongings. Document if belongings sent with patient or family member. If patient transferred to another unit, pack belongings, may have to gather medications, take medical record; document that belongings and records sent with patient
Discharge Home, another hospital, extended care facility, funeral home discharge assessment and documentation Disposition of belongings
Summary Medical records provide vital information about the patient over a period of time Follow facility policy and HIPAA guidelines re: access, storage, retrieval