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A medical record is a comprehensive report that lists all the data that is created or acquired during a person’s course through a healthcare facility. It records details of any treatment plans of present or past, medical reports, tests, diseases, illnesses, medical checkups, etc. that a person has had in his life. Apart from the obvious purpose of documenting a person’s medical history or care record for emergency situations, a person’s medical record is also important for certain legal and financial information.
It is also used in quality improvement and research processes. So, medical records are used for informing others, recalling observations, instructing students, gaining knowledge, monitoring performance, and for justifying interventions (Reiser, 1991). A person must possess his/her medical record at all times. Medical Records Schemes The medical records stored in healthcare organizations are either paper-based or computer-based (digital format). Since information in medical records has to be shared amongst the professionals forming the healthcare team, the researchers, legal or financial firms, medical records must be in a format that can easily be accessed, transferred, recorded, updated and consulted.
Paper-based records have the obvious accessibility limitations and tend to be less organized as they are maintained in files and folders. They require storage spaces. The information in these records is usually incomplete. They may only comprise of the basic medical information, e.g. blood group type, current medicinal treatment or physical disease, etc. or data till a recent date. Carrying them everywhere is not feasible e.g. for military personnel or across borders. The terminologies used (abbreviations, etc.) may not be standardized and the handwriting may not be credible.
Additionally, paper-based records have a constant threat of being ruined in case natural calamities like floods, fire, etc. Electronic medical records (EMR) help bridge this information storage, availability, access and retrieval gap in paper-based records by digitizing all the information. As EMR is computer based, information can reach the medical staff even before the patient reaches the healthcare center, records have backup copies in case of fire, flood, etc. A large acute care hospital was struck by a tornado that hit Joplin, Missouri, in late May 2011.
But as the hospital had fully incorporated an electronic records system, patients’ records were accessible without any delay (“Status of Electric”, 2011). Medical record constitutes the entire medical history of a person. Data is more organized as it consolidated from various points of cares. The record automatically updates in case of healthcare prescriptions and visits. Despite the technological advancements and advantages of EMR, majority of healthcare organizations around the world still maintain and operate on paper-based medical records.
The quality of patient safety and care is without doubt compromised. One reason for this reluctance in transitioning is the substantial initial conversions costs (software, hardware, and technical staff) from paper-based medical records to EMR. However, due to the ever-increasing use of Internet and the electronic
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