Medical Records

1. Medical Records

2. 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

3. 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

4. Types/format • Outpatient • Physician’s practice • Clinic • History and physical • Lab/radiological reports • Physician’s orders • Vitals signs flow sheet • Physician’s progress notes

5. 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

6. 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

7. Discharge • Home, another hospital, extended care facility, funeral home • discharge assessment and documentation • Disposition of belongings

8. Summary • Medical records provide vital information about the patient over a period of time • Follow facility policy and HIPAA guidelines re: access, storage, retrieval