Information Management: The Medical Record as a Legal Document

3167 Words 13 Pages
In order for hospitals and other health care facilities to prevent the thousands of deaths and injuries that occur every year due to medical errors; health care systems were required to implement new record keeping technology. This technology has made patient information and treatment accessible to all who needed to see it. This is especially important when a patient has more than one attending physician and their care relies on each doctor knowing what the other one has done, serving as the prime communication tool between doctors. If organizations do not centralize their technology and essentially their patient databases, the potential for duplicate work or inefficient patient care can exponentially increase. These high tech medical …show more content…
These records make up part of the hospital’s information system. Said information systems must be readily accessible and will include all necessary information including, human resources, financial information, and most importantly medical records. By updating a patient’s record and making it readily available to all health care providers, the information system allows a flow of information from one department to the other; without risking the loss of paper notes on the way (Pozgar 2007). A medical record has many essential roles within any health care organization; these records contain a plethora of medical information for the patient. Medical records are required to contain correct and precise information such as patient demographics (address, phone number, and age), any consent and authorization forms that the patient signed for treatment, family and patient medical history, and any diagnosis that is made using the patient’s medical history and their current health complaints. All information that pertains to the patient must be included in their record. Along with the patient information the medical record is required to contain all doctor orders, nurse notes, progress reports, diagnostic reports, fluid intake and output amounts and frequency, pain management, and all discharge planning and patient education (Pozgar 2007). It is beyond important that all health