9.2:
Purpose of Health Records I
The purposes of medical records are described in this lesson.
Health records are communication tools among the health team members used to promote continuity of care for the patient among the different departments during their hospital stay.
Health records also help in reviewing diagnostic and therapeutic orders. For example, healthcare providers can verify any diagnostic tests performed on the patient since admission and review pertinent care orders.
Records help in planning care. Healthcare staff working with the patient can access the baseline and ongoing data and observe the patient's progress.
Records serve as reference material for research, improving new approaches to patient care and enhancing professional knowledge.
Lastly, health records are used in quality reviews. Accreditation agencies perform frequent chart audits as part of a quality assurance program to review a nurse's competence and the hospital's standards.
All these help to identify areas that need improvement. Deficiencies can be addressed by providing staff with in-service training to improve the quality of care.
9.2:
Purpose of Health Records I
The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
- • Communication: Health records are a crucial communication tool among the various healthcare team members. These records help ensure patients receive the best possible care by promoting continuity of communication among the different departments involved in their treatment. Health records help minimize errors, maximize efficiency, and reduce the risk of miscommunication between healthcare providers by providing a complete view of a patient's medical history, current health status, and ongoing treatments and medications.
- • Diagnostic and Therapeutic Decision Support: Health records play a critical role in healthcare by facilitating the review of diagnostic and therapeutic orders. By accurately describing a patient's medical history, healthcare providers can make informed decisions about which diagnostic tests to order and which treatments to administer.
- • Care Planning: Records are essential for planning and delivering patient care. Baseline data and ongoing progress are documented to inform healthcare staff about the patient's needs and enable them to make informed choices, ensuring the best possible care that aligns with the patient's individual goals.
- • Research Reference Material: Records are crucial as valuable reference material for research purposes. They facilitate the development of new and innovative patient care approaches while significantly advancing professional knowledge in various fields of expertise.
- • For example, in a recent study published in the "Journal of Innovative Healthcare," researchers emphasized the critical role of comprehensive medical records in advancing patient care. The study analyzed over 10,000 patient records from multiple hospitals, focusing on treatment outcomes and patient demographics. The findings revealed new patterns in disease progression and treatment efficacy, particularly in chronic illnesses like diabetes and heart disease. Researchers could propose new treatment protocols by leveraging these records, significantly improving patient recovery rates. This study exemplifies how meticulously maintained medical records can be a goldmine for research, leading to groundbreaking advancements in healthcare.
- • Additionally, medical records serve as a cornerstone for exploration and analysis, enabling professionals to make well-informed decisions and foster ongoing enhancements in patient care.
- • Quality Review and Assurance: Nursing documentation, a critical component of the medical record, is integral to assessing quality care. Accreditation agencies such as Joint Commission International (JCI) and the National Committee for Quality Assurance (NCQA) audit charts as part of a quality assurance program to review nurses' performance in providing quality patient care. These audits help identify gaps or errors in patient care, improving the overall quality of care provided. By reviewing health records, accreditation agencies can assess the nurse's adherence to protocols, accuracy in documenting patient information, and the effectiveness of the care provided.
In summary, health records are multifaceted tools that support effective communication, decision-making, care planning, research, and quality assurance in the healthcare system. They contribute to the overall goal of providing the best possible care to patients while maintaining accuracy, efficiency, and continuous improvement in healthcare practices.