Talk:Medical record

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This

This record is a whole long write. I've tried to do it in several sittings; however, I decided to string out the headers and do some fill in afterward. DrGnu 07:05, 3 Nov 2004 (UTC)

should be archived now Sanjiv swarup (talk) 04:49, 22 June 2008 (UTC)[reply]

Introductory paragraph

The second sentence in the introductory paragraph states: "Although medical records are held by the physician they are the legal property of the patient." Perhaps this depends upon the state or country. In my state, medical records are the legal property of the physician but the patient is legally entitled to a copy of anything in his or her record. Anyone monitoring this page who would care to comment? Edwardian 05:56, 5 August 2005 (UTC)[reply]

I did a brief search and found multiple references from multiple States stating that the medical record belongs to the physician, but none stating it belongs to the patient [1][2][3][4][5]. I think that is sufficient to warrant the change right now, although maybe those outside the U.S. could comment. Edwardian 05:35, 25 August 2005 (UTC)[reply]

In Australia, in general, the medical records held in a doctor's surgery/office are held to belong to the doctor, but the information contained belongs to the patient! In hospitals the medical record is the property of the hospital. Privacy legislation here means that although the record doesn't belong to the patient, the patient's permission must be sought to release the information, to another doctor (for example taking over care) or to an insurance company, to the Roads and Traffic Authority (for drivers licence information). Lbandler 07:41, 20 September 2005 (UTC)[reply]

Temperature

I rewrote this section, partly to tidy english (eg "Prolonged elevated .....Prolonged depressions....") and partly as some inaccuracies.

The need to record temperature in the medical record is what is required in this article, not a full discussion on all different methods of measurement and their relative pros & cons. So I wanted to cut down on the fuller discussion (the article will get longer as other sections are completed).
Likewise core temperature spent too much discussing other methods and so I simplified that too and place the additional info in a new article of Temperature examination
Having the current blind links to oral temperature & rectal temperature is not, I think, appropriate as neither ever will need be a full article and both can be encompassed in a single page (hence Temperature examination)
Thermosensative material skin measurement is not primarily used in operative measurements (but thermocouple sensing is), rather they are sold in the tens of thousands as a simple children's thermometer
Thermocouples need direct contact with what the are to measure the temperature of and are not used by Ear thermometers which do not touch the ear drum. Ear thermometers instead use a device to measure infrared heat emmission. Thermocouples are though indeed found in electronic thermometers, but of the types used for oral, armpit or rectal recording. Thermocouples therefore have replaced glass mercury thermometers (now banned from use in Europe due to toxicity if the thermometer breaks open).

NB I thank Gene Nygaard for correcting my initial Celsius/Farenheit conversion errors and pointing out that the values are not a fixed value. David Ruben^talk 11:13, 24 September 2005 (UTC)[reply]

All that needs be said about temperature on a page about medical records is to mention that there are four vital signs that are routinely recorded (temperature, respiratory rate, pulse, blood pressure), that temperature is one of them, and that "The patient's temperature is recorded at various times during the day, so it can be examined for patterns which suggest fever." This is not the place to discuss methods. - Nunh-huh 11:23, 24 September 2005 (UTC)[reply]

- I tend agree, but likewise for the whole paragraphs on blood pressure etc. Whilst each is well written and provides good overviews to the fuller topics (nice multiple links within WP), such should be under physical examination - I'll move them there, unless anyone objects in the next day.David Ruben^talk 11:37, 24 September 2005 (UTC)[reply]

re merge suggestion with Medical records

User:Lotsofissues has suggested a merging with the existing Medical records. There are two separate aspects covered by both the current Medical record and Medical records

Clinical: the contents of an individual patient record, ie that it consists of has past history, current problems, correspondence and that each clinical encounter results in details of history, examination, investigations, diagnosis & treatments. It also contains social & family history etc etc.
Administrative: the issue of medical records and accesibility to ones own notes, disclosure to others (ie confidentiality, legal requirements). Also issues of being comprehemnsive & contemparous and kept notes for many years to allow problems (education, audit, verification, disputes etc) to be managed.

I think both aspects are sufficienty large that a single article would be too long. However careful redirection is needed between the two pages as 'Medical record' is so very close to 'Medical records'. Either that or rename them a 'Medical record (clinical)' and 'Medical records (administation)' with redirects from the current pages ? For now, much of the current WP:MCOTW article would be better within Medical records and both articles should be edited as this weeks project? David Ruben^talk 11:34, 24 September 2005 (UTC)[reply]

Thanks for completing the tagging. Though, if you wish to create a separate article for the administrative structure behind medical records, I think you should create a more specific title than "medical records". -lots of issues | leave me a message 12:06, 24 September 2005 (UTC)[reply]
I agree that the articles should be merged. I like the idea of an eventual "clinical" and "administrative" division of the article. Edwardian 22:06, 24 September 2005 (UTC)[reply]

I agree - I like the idea of a clinical medical record and an administrative medical record division. This is a useful way to think about it. I think that the [medical record] and [medical records] be merged. However I think that there is some confusion about medical record/s/history because doctors tend to use words that are in general use in specific ways.

Yes, I would say merge them and move all the physical examination stuff to the physical examination article. --WS 09:20, 28 September 2005 (UTC)[reply]

I agree with that, too. This article is getting much too detailed in areas it doesn't need to be. Edwardian 05:06, 29 September 2005 (UTC)[reply]

OK, seems consensus to merge (with info off to physical examination) - I'm happy to do this, and will do so over the next few days - David Ruben^talk 00:53, 30 September 2005 (UTC)[reply]

Merge from Medical records

Medical records merged into this article; if you wish to see its history of edits then follow this link. Likewise details of the examination moved to the existing physical examination article. - David Ruben^talk 16:57, 30 September 2005 (UTC)[reply]

Excellent work! Edwardian 19:28, 30 September 2005 (UTC)[reply]

The whole article is much better now! --WS 00:06, 1 October 2005 (UTC)[reply]

In fact, I think it is now good enough to justify removing the cleanup tag, which I did. --WS 00:07, 1 October 2005 (UTC)[reply]

It reads a lot better and looks a lot better InvictaHOG 04:31, 4 October 2005 (UTC)[reply]

Updated the Contents section

I went ahead and made some additions, deletions, and formatting changes to the contents section. It seemed fairly jumbled to me and hopefully I made a dent in organizing it. I won't be offended if you think it's worse! I don't know if there's some easy way to make a box or something with the main headers of the contents section - I feel that the bullets do a little better job letting people know where things belong but think it would be nice to have something to quickly scan showing that demographics, progress notes, etc. all belong directly to contents. In any event, I'm not as qualified to change the administrative issues, though I believe they need quite a bit of work! It's difficult to tell what's the US and what's the UK. We should probably just divide up. Also, the EMR bit is not straight-forward. I might take a stab at it tomorrow...

The administrative portion is still quite messy. I've pretty much finished what I hoped to accomplish on the clinical side. I'm trying to research the various questions on the administrative side, but it's slow going. I think the whole section may benefit from a re-write and new structure. InvictaHOG 02:31, 5 October 2005 (UTC)[reply]

Major overhaul of the administrative portion. I still have a ways to go, though. Will continue to work on Security, discussion of electronic record systems, etc. #InvictaHOG 03:29, 6 October 2005 (UTC)[reply]

Duty To Review Medical Record

Is there a duty to review the medical record prior to treating the patient? What is the scope of the physicians or nurses duty? Should this be part of the article? - Bill Smoot

Thought this had been covered by the 'Purpose' section, but perhaps need to more explicitly state the legal implications of this ? There is a duty for anyone to "put themselves in a suitable position" to offer appropriate treatment. However need to think carefully on wording - a doctor in an Emergency room has a duty to obtain info from the patient if concious, else attending 3rd parties if present, consider if need or time to contact the patient's usual physician (if known). But still possible will need to treat without any background information... - David Ruben^talk 19:06, 5 October 2005 (UTC)[reply]

I am not a doctor but I am familiar with a case where a doctor did not review the record prior to rendering treatment and this may have led to the death of a patient from pulmonary emboli. I stumbled on your article and just threw this out as a question because it was a question that I had and so I thought others might have it as well. Bill Smoot 01:31, 6 October 2005 (UTC)[reply]

I don't know the answer to your question - how much of the medical record is the physician responsible for is a good question. Many medical records are veritable tomes - no one could be expected to have memorized them for each patient. That said, I'm sure that the legal system does! I'll put an e-mail out to our legal department tomorrow and will update the article with anything I find. InvictaHOG 03:32, 6 October 2005 (UTC)[reply]

Ethical Considerations

Could there be a section on ethical considerations? Eg, Should patients have the right to request that medical records not be kept? Should patients have the right to ask that medical records be destroyed? Should patients have more say over who gets to see their medical records, for instance saying that *only* their own doctor can see them, not other doctors in the same practice or reception staff? Should patients have the right to anonymous health care? Personally, I hate the fact that doctors keep records about me, if I had a say in it, I'd have them burnt in 2 seconds flat. It also makes alternative health providers (like naturopaths, acupuncturists etc) seem a lot more attractive, because at least with them your anonymity is protected, and no records are kept.

Destruction in the US

How long are medical records kept in the US? I do not see this mentioned in the article.Danny (talk) 13:54, 9 January 2008 (UTC)[reply]

About my new proposed definition - by: alo_world

I think there should be no doubt that these 2 terms - Medical Records and Health Reacords - are, and can be, used interchangeably as synonyms, without major conceptual incorrections. In fact, there is usually no significant loss of meaning by expressing one term over the other.

Ceci étant dit, let us not overemphasize that there should be no confusion between them, either; specially if a specific context requires us to choose between one over the other when meaning could be comprimised if equivalence is not applicable interchangeably. Thus, I proposed one section on that, hoping it will help clarify these discussions.

alo_world —Preceding unsigned comment added by Alo world (talk • contribs) 08:18, 30 March 2009 (UTC)[reply]

What are you trying to state ? "comprimised if equivalence is not applicable" defeats me :-) I've reverted you edit for being uncited personal supposition (WP:NOR), off topic (practice of medicine and its ethics of no harm, beneficence etc does not belong in this article), and your 'see also' addition of Ethical considerations does not exist. 00:21, 31 March 2009 (UTC)

MRN vs PF

I know what MRN is: medical record number, but I swear I've heard other physicians say PF#... but I can't figure out what the acroyn for that might be. Anyone? Is there an article that addresses these abbreviations relating to the medical record? 163.40.12.37 (talk) 19:35, 8 December 2009 (UTC)[reply]

medical records clerk

What is the job outline for medical records clerk? —Preceding unsigned comment added by 198.99.244.32 (talk) 20:50, 18 February 2010 (UTC)[reply]

Related discussion at Electronic medical record

I've started a discussion at the electronic medical record page; please participate in the discussion there as the links being added here seem to be related and we can keep the discussion together. Thanks! Flowanda | Talk 20:11, 18 April 2010 (UTC)[reply]

As there appears to be no legitimate discussion or reason why these links are needed on the talk page, I am removing them here and elsewhere. Flowanda | Talk 10:52, 11 May 2010 (UTC)[reply]

I've tried to fix an inconsistency, but then the edit has been reverted

I've edited this article to fix an inconsistency yesterday (this edit)

There had been stated 'Hence the patient's record belongs to the patient.', in the article's 'Informational self-determination' section.

Actually, reading further on, it came out that:

In US: 'belongs to the patient', nut with "citation needed"
In UK: Does not belong to the patient
In Germany: 'not explicitly codifed'

and so on.

So it's not true that 'the patient's record belongs to the patient', and there was an inconsistency in the article.

I fixed it, making an edit, changing the sentence to 'Hence the should patient's record belongs to the patient, but it seldom happends.' (should = it should be, but not always is. It seldom = becouse it does not happend in any of the countries that were dealt in the article).

But that edit was immediately reverted by another user.

Why? Is the article better with inconsistency in it?
With immediatlty I mean that if I look at article's history, my edit was at 23:27, 7 July 2010, the reverting edit was at 23:27, 7 July 2010. How can an human user (the edit is not marked as made by a bot) read an edit, understand it in the context of the sentence and the nerby ones, decide that the edit should be reverted, and actually make the revert in less than a minute?

(Sorry for my not so good english, I'm not English native speaker) --79.20.147.77 (talk) 20:37, 8 July 2010 (UTC)[reply]

The edit in question appeared to be a test edit, and was reverted as such.
Using the anti-vandal tool Huggle, I only see the diff. I saw header, edited line that made no sense, and another header. I reverted the edit as a test edit, assuming in good faith that the editor had accidentally clicked "Save Page" instead of "Show Preview".

--ANowlin: talk 23:25, 8 July 2010 (UTC)[reply]

Actually I can not understand why, "assuming in good fait", a good eit should be regarded as a "test edit". Why did the edit seem like a test?!

Can I re-insert that? --79.6.9.187 (talk) 09:51, 21 November 2010 (UTC)[reply]

This is 10 years late, and I can't 'ping' you so you could see it, but I'll say that the reverter was, I think, trying to tell you that he reverted it because the wording you put there made no sense. See where the reverter said, "edited line that made no sense". I don't think you should re-insert it as you wrote it, although the information you were trying to add probably should be there, in different words. You wrote, "Hence the should patient's record belongs to the patient, but it seldom happends.", and that sentence is both very poor English (you mentioned that English is not your native language, but this is an English language Wiki page), and also though what you wrote (that it should belong to the patient) could be a somewhat reasonable opinion, it is an opinion, not a referenced fact (as required for Wikipedia). In corrected English, you might have meant, "Hence the patient's record should belong to the patient, but it seldom happens.", but the idea that it seldom happens is not exactly what the fact that it happens differently in different places means, so you can't just say 'it seldom happens'. You could say that different places define who has ownership differently. Or the sentence currently in the lead could be perhaps changed from, "Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.", to, "Although the storage equipment and media for medical records generally is the property of the health care provider, the actual facts on record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request." UnderEducatedGeezer (talk) 07:03, 19 July 2020 (UTC)[reply]

Medical Record's Creation Talk

Doctor's make their patient's medical records or their own medical record technician it depends some doctor's know how to make medical records some don;t so the point of a'medical record technician is to help the doctors with making their patient's medical records medicals are private and inportant they must be placed in a folder or a medical record case or a filing cabinet. to see medical records examples or forms or real medical records ask your doctor or go online.— Preceding unsigned comment added by 98.110.215.132 (talk • contribs) 14:47, 26 February 2011

Norway

There is no section about Norway. This link [6] tells about the Minister of Health's suggestion for a law proposal: that doctors working at any particular office should have access to all the medical records that the other doctors there have written (while working there).--85.164.146.94 (talk) 13:34, 18 December 2011 (UTC)[reply]

History section

The history of the use of medical records is beyond the scope of this article. However a brief summary of the origins of the medical record in the West may be found at the following website: "History of medical record-keeping", Casebooks Project (http://www.magicandmedicine.hps.cam.ac.uk/on-astrological-medicine/further-reading/history-of-medical-record-keeping/) (Accessed 2012-09-25). I removed this. A better solution would be to actually write a history section.-- Atlantima ~✿~ (talk) 21:55, 26 April 2013 (UTC)[reply]

Media Applied Section - Mayo Clinic

The "Media Applied" section has a claim that implies that the Mayo Clinic invented a single-dosier medical record. This really needs a citation - I have placed a tag there, in the hopes that someone will find a citation.(I see the Mayo Clinic page itself says that the Clinic "Created an integrated medical record" but gives no details, and I don't think that the Clinic's own advert page can be used as a reliable citation.). In addition, there does not appear to be a logical reason why this claim is in the "Media Applied" section. Kmasters0 (talk) 07:35, 21 September 2016 (UTC)[reply]

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Privacy section

Currently there is a parochial template(I don't know what else it's called), informing readers that the Privacy section is primarily about Privacy in the United States. Might it be appropriate to begin that section (until or if the section is improved to cover Privacy concerns in other places), by stating, "In the United States, ..."? Would anyone have any objection if I added that statement to the beginning of the section? And the next sentence says, "Not only is it bound by the Code of Ethics...", but I wonder exactly what does 'it' refer to? Is it referring to HIPAA in particular, or Privacy in general, or what? If it's Privacy in general, couldn't the word 'privacy'(or the phrase 'the privacy of patients') replace 'it'? And then there is a sentence which says, "The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel.", but shouldn't the word 'implies' be 'applies', to make some sense (with the later change of 'in' to 'to'), so that the sentence would read, "The maintenance of the confidentiality and privacy of patients applies first of all to the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel." (minus the bolding of the words)? I'm not comfortable just making those changes without some discussion, even though I think my changes make the sentence make better sense. UnderEducatedGeezer (talk) 05:58, 19 July 2020 (UTC)[reply]

And couldn't the phrase, 'physical exploration' (in the sentence following the above mentioned one) be changed to 'physical examination'? And also, the phrase, '...the privacy at the time of the information to the relatives,...", wouldn't that phrase make much more sense if it were, 'the privacy at the time of giving information to the relatives,'? UnderEducatedGeezer (talk) 06:10, 19 July 2020 (UTC)[reply]

Word choice in opening paragraph

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.

Someone should change 'jurisdiction' to 'specialty' or 'area of expertise' or better yet 'discipline'. 'Jurisdiction' is a special word that means where the 'law can be spoken' and has nothing to do with whether a doctor under the law is seen as a legal provider of care. 71.225.252.204 (talk) 18:39, 26 July 2021 (UTC)[reply]

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