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 F = Fordítás

        Health record or medical chart is a systematic documentation of a patient's medical history and care. F FA01a

         The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history.   F FA0 

            Medical records are intensely personal documents and there are many ethical and legal issues surrounding them, such as the degree of third-party access and appropriate storage and disposal.   F  FA02a

         Although medical records are traditionally compiled and stored by health care providers, personal health records maintained by  individual patients have become more popular in recent years. F  FA01b
 

     Purpose   Cél

         The information contained in the medical record allows health care providers to provide continuity of care to individual patients.   F  FA1Purpose1

         The medical record also serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care.  F FA1Purpose2

        Assisting in protecting the legal interest of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient.  F FA1Purpose3

              In addition, the medical record may serve as a document to educate medical students, resident physicians  to provide data for internal hospital auditing and quality assurance, and to provide data for medical research.  F  FA1Purpose4

         Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.  F   FA1Purpose5

     Format  Formátum

         Traditionally, medical records have been written on paper and kept in folders.  F FA1Format1 

         These folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues.  F FA1Format2 

         Active records are usually housed at the clinical site, but older records (eg those of the deceased) are often kept in separate facilities. F FA1Format3

         The advent of electronic medical records has changed not only the format of medical records, but has increased accessibility of files. F FA1Format4

  ===========================================

     Contents M1A6    Tartalma

         Although the specific content of the medical record may vary depending upon the speciality and location, it usually contains the patient's identification information.  F  FA1Contents1

          It also contains the patient's health history (what the patient tells the health care providers about his or her past and present health status); and the patient's medical examination findings (what the health care providers observe when the patient is examined).  F FA1Contents2

              Other information may include lab test results; medications prescribed; referrals ordered to health care providers; educational materials provided; and what plans there are for further care. F   FA1Contents3

              Also  included are patient instructions for self-care and return visits. In some places, billing information is considered to be part of the medical record. F   FA1Contents4

      Demographics

         Demographics include information regarding the patient, which is not medical in nature.  F  FA1Demog1

          It is often information to locate the patient including identifying numbers, addresses, and contact numbers.  F   FA1Demog2 

         It may contain information about race and religion as well as workplace and type of occupational information.  F   FA1Demog3

         It may also contain information regarding the patient's health insurance. It is common to also find emergency contacts located in this section of the medical chart.    F  FA1Demog4

_________________________

 B

     Past Medical history   /PMH/

         The medical history is a longitudinal record of what has happened to the patient since birth.  F  FB1HistoryA

          It chronicles diseases, major and minor illnesses as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient.  F FB1HistoryB

          As a result, it may often give clues to current disease states. It includes several subsets as detailed below.   F FB1HistoryC

     Surgical history

The surgical history is a chronicle of surgeries performed on the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.   F   FB2HistoryA

     Obstetric history

The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.  F  FB2HistoryB

      Medications and medical allergies

      The medical record  contains a summary of the patient's current {körrent} and previous medications as well as any medical allergies.  F  FB3HistoryA

    Family history

       The family history lists the health status of immediate {immídiat} family members as well as their causes of death (if known).   F  FB3HistoryB

      It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart.     It is a valuable {váljuabl} asset in predicting some outcomes for the patient.  F  FB3HistoryC

    Social history

      The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers {karriers} and trainings, schooling and religious training.   F  FB4HistoryA

         It is helpful for the physician to know what sorts of community support the patient might expect during a major illness.   F  FB4HistoryB

         It may explain the behavior {bihévjör} of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (ie occupational exposure to asbestos).  F  FB4HistoryC

  Habits

      Various habits which impact health, such as tobacco use, alcohol intake, recreational drug use, exercise, and diet are chronicled, often as part of the social history.  F  FB4HistoryD

       This section may also include more intimate details such as sexual habits and sexual preferences.   F FB4HistoryE

      Immunization history 

         The history of vaccination is included. Any blood tests proving immunity will also be included in this section.   F  FB5HistoryA

    Growth chart and developmental history

          For children and teenagers, {tínédzsers} charts documenting growth as it compares to other children of the same age is included so that health care providers can follow the child's growth over time.  F  FB5HistoryB

            Many diseases and social stresses can affect growth and longitudinal charting can thus provide a clue to underlying illness.   F  FB5HistoryC

         Additionally, a child's behavior {bihévjör} (such as timing of walking, talking,  etc) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.  F  FB5HistoryD

  MrROS01  Review of Systems    /ROS/

The  review of systems is a systematic review of all organs systems, questioning and recording symptoms of disease, affecting a specific organ, but NOT related to the present illness.  F  FROS1

   MrROS02 Questions are addressed to the patient of each symptoms to elicit yes or no answers or description.   F   FROS2

   MrROS03  General

The symptoms described  here are of general nature, how the patient feels, attitude, {attityúd} appearance,{appírensz} weight changes, temperature aberration (fever, chills), states of consciousness,  sleeping habits, general strength, ability to conduct usual activities, exercise tolerance.  F   FROS2

   MrROS04  Skin

Color, texture, pigmentations, rashes, dryness, lesions, changes, masses, prior problems and treatments. F   FROS2

   MrROS05 HEENT Head, Eyes, Ears, Nose, and Throat

Headache (location, time of onset, duration, precipitating factors), head injury, vertigo, lightheadedness . F   FROS2

   MrROS06 Visual disturbances, tearing, glasses, blurred or double vision, blind spots, flashing lights, glaucoma  F   FROS2

   MrROS07   Decreased hearing, ringing, earache, drainage

Nose: Stufffyness of the nose, nose bleeds, obstruction, blockage, discharge, hay fever, sinus pain

   MrROS08  Throat:   Sore throat, hoarseness, postnasal drip

Mouth: lesions, dental problems, gums, gingival bleeding, dentures, sores

Neck: swollen glands, lumps, pain,  masses in the neck, stiff neck.  F   FROS2

   MrROS09 Breasts

Lumps, pain, assymetry, nipple discharge, breast feeding history, self exams, mammograms.  F   FROS1

   MrROS10  Respiratory

Pain, (location, quality, relation to respiration), cough (productive or dry, time of day), sputum (amount, color),  hemoptysis, shortness of  breath, wheezing, crepitation, respiratory infections, tuberculosis (exposure to it),  fever, night sweats.   F   FROS10

   MrROS11 Cardiovascular

Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea, nocturnal paroxysmal dyspnea, edema, cyanosis, hypertension, heart murmurs, varicosities, phlebitis, claudication.   F   FROS11

   MrROS12  Gastrointestinal

Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn, GERD (gastroesophageal reflux), eructation, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling), flatulence, hemorrhoids, recent changes in bowel habits.  F   FROS12

   MrROS13  Genitourinary

   MrROS15  Musculoskeletal

   MrROS16  Neurologic/Psychiatric

   MrROS18 Allergic/Immunologic/Lymphatic/Endocrine

     Medical encounters

           Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms.

          Hospital admission documentation (ie when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care.

         Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR).

          This includes a problem list of diagnoses or a "SOAP" method of documentation ( Subjective, Objective, Assessment and Plan) for each visit.

          Each encounter will generally contain the aspects below: 

C

      Chief complaint

         This is the problem that has brought the patient to see the doctor. Information on the nature and duration of the problem will be explored.

History of the present illness

         A detailed exploration of the symptoms that the patient is experiencing which have caused the patient to seek medical attention.

Physical examination

         The physical examination is the recording of observations of the patient.

         This includes the vital signs and examination of the different organ systems, especially ones which might directly be responsible for the symptoms that the patient is experiencing.

     Assessment and plan

         The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms.

         The plan documents the expected course of action to address the symptoms (diagnosis, differential diagnosis, plan of investigation and proposed procedures and treatment).

Orders

         Written orders by medical providers are included in the medical record.

         These detail the instructions given to other members of the health care team by the primary providers.

    Progress notes

         When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc.

         These often take the form of a SOAP note and are entered by all members of the health care team (doctors, nurses, dietitians, clinical pharmacists, respiratory therapists, etc).

         They are kept in chronological order and document the sequence of events leading to the current state of health.

     Test results

         The results of testing, such as blood tests (eg complete blood count) radiology examinations (eg X-rays), pathology (eg biopsy results), or specialized testing (eg pulmonary function testing) are included.

         Often, as in the case of X-rays, a written report of the findings is included in lieu of the actual film.

 Other information

         Many other items are variably kept within the medical record.

         Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.

D

     Administrative issues

         Medical records are legal documents and are subject to the laws of the country/state in which they are produced.

         As such, there is great variability in rule governing production, ownership, accessibility, and destruction.

Production

         In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper.

         Errors in the record should be struck with a single line and initialed by the author. Orders and notes must be signed by the author.

         Electronic versions require an electronic signature.

     Ownership

         In the United States, the data contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record.

         Therefore, patients have the right to ensure that the information contained in their record is accurate.

         Patients can petition their health care provider to remedy factually incorrect information in their records.

 Accessibility

         In the United States, the most basic rules governing access to a medical record dictate that only the patient and the health care providers directly involved in delivering care have the right to view the record.

         The patient, however, may grant consent for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.

     Capacity

         When a patient does not have capacity (is not legally able) to make decisions regarding his or her own care, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists).

         Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf.

         Those without capacity include the comatose, minors (unless emancipated) and patients with incapacitating psychiatric illness or intoxication.

 Medical emergency

         In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been drafted previously (such as an advance directive)

Research, auditing, and evaluation

         Individuals involved in medical research, financial or management audits, or program evaluation have access to the medical record.

         They are not allowed access to any identifying information, however.

    Risk of death or harm

Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others.

         Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (ie, information from illicit drug testing cannot be used to bring charges of possession against a patient).

         In the United Kingdom, the Data Protection Acts and later the Freedom of Information Act 2000, gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality.

          That is  information from another family member or where a patient has asked for information not to be disclosed to third parties or would be harmful to the patient's well-being (eg some psychiatric assessments).

         Also the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.

      Destruction

         In general, entities in possession of medical records are required to maintain those records for a given period of time. In the United Kingdom, medical records are required for the lifetime of a patent and legally for as long as the time that complaint action can be brought.

         Generally in the UK any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years).

         Medical records are required many years after a patient’s death to investigate illnesses within a community (e.g. industrial or environmental disease or even of doctors committing murders.

Abuses

• The outsourcing of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data.

• Falsification of a medical record by a medical professional is a felony in most United States jurisdictions.

• Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.  713 WORDS

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E    SOAP

     The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by doctors and other health care providers to write out notes in a patient's chart.

         Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing.

     Components

         The four components of a SOAP note are Subjective, Objective, Assessment, and Prognosis.

         The length and focus of each component of a SOAP note varies depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note.

         It and will focus on issues that relate to post-surgical status (e.g., it will often be noted whether the patient has passed gas, because if they have, it is considered by many physicians to be safer to allow them to eat.)

     Subjective component

         This describes the patient's current condition in narrative form , usually beginning with the patient's age and gender.

         The history or state of experienced symptoms are recorded in the patient's own words. It will include all pertinent and negative symptoms under review of body systems.

         Pertinent Medical history, surgical history, family history, social history along with current medications and allergies are also recorded.

     Objective component

         Includes vital signs, findings from physical examinations Eg posture, bruising, abnormalities, and results from laboratory tests.

 Assessment

         s a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely.

 Plan

         This is what the health care provider will do to treat the patient's concerns. This should address each item of the differential diagnosis.

         A note of what was discussed or advised with the patient as well as timings for further review or follow-up may also be included.

     An example

A very rough example follows for a patient being reviewed following an appendectomy:

S: No Chest Pain or Shortness of Breath. "Feeling better today." Patient reports flatus.

O: [Vital signs, lab data, and physical exam results would be recorded here.]

A: Patient is a 37 year old man on post-operative day 2 for laparoscopic appendectomy, recently passed flatus.

P: Recovering well. Advance diet. Continue to monitor labs. Prepare for discharge home tomorrow morning.

Note that the plan itself includes various components:

Diagnostic component - continue to monitor labs

Therapeutic component - advance diet

Patient education component - that is progressing well

Disposition component - discharge to home in the morning

 

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