A THE HEALTH RECORD

A health record is a written collection of information about a patient. It is

derived from the patient's first encounter or treatment at a hospital, clinic or
other primary health care centre. The health record is thus a record of all
the procedures carried out on that patient, whilst he is in hospital or under
treatment at a clinic or centre. It should contain the past medical history of
the patient, including opinions, investigations and other details relevant to
the health of the patient. As a document it may appear in many shapes and
sizes with varied information related to the care of the patient recorded by
many persons in many ways. In physical appearance, it consists of a
number of sheets of paper or cards and may be placed in a cover or
envelope. In more advanced systems, the information may be recorded
digitally in a computer; the sheets of paper scanned onto optical media or
the actual sheets may be microfilmed.

Huffman (1994) defines a health record as "a compilation of pertinent facts

of a patient's life and health history, including past and present illness(es)
and treatment(s), written by the health professionals contributing to that
patient's care. The health record must be compiled in a timely manner and
contain sufficient data to identify the patient, support the diagnosis, justify the
treatment, and accurately document the results."

The actual physical record should be of an acceptable size and standardised

on suitable forms, as far as possible to enable interchange of information,
from hospital to hospital, hospital to health centre, hospital to general
practitioner or other primary health worker. The record must contain
sufficient forms to cover the needs of the 'centre', without unnecessary and
useless forms, which add bulk. The forms should be of a standard size
within each record system.

B. PURPOSE OF THE HEALTH RECORD

As indicated above a good complete health record should encompass all

information about a patient's health, ill health and treatment over a period of
time and be readily accessible.

Health records are kept for:

1. communication purposes
2. continuity of patient care
3. evaluation of patient care
4. medico-legal purposes
5. statistical purposes
6. research and education.

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7. historical purposes

1. Communication purposes

Health records are kept initially for communication between persons

responsible for the care of the patient for present and future needs.
Many health professionals often see a patient. In a hospital the
registration staff collects identification information and finds out the
patient's financial status. While under care, others who may be
involved in looking after a patient and who contribute to the health
record include:

 all medical staff including consultants, physicians, surgeons,

obstetricians, etc
 nurses
 physical therapists
 occupational therapists
 medical social workers
 laboratory technicians
 dieticians
 medical students
 radiologists, etc.

All the data collected about a patient must be recorded and

coordinated. The findings of each professional must be available for
others to perform their function intelligently, especially the doctor
responsible for the patient who must make the final diagnosis and order
treatment on the basis of all the documented findings.

This first use of the record is a personal one and is in the interest of the
patient for both present and future care.

2. Continuity of patient care

The patient may be readmitted to the same or another hospital or visit a

clinic where all his past medical history should be available for
assessment in the light of current symptoms. Communications on the
basis of the health record is essential between hospitals, clinics and
primary health workers in contact with the patient. It is vital that the
primary health worker, who is responsible for the patient as a whole,
should receive information about a patient's hospitalisation as soon as
possible after the patient is discharged from hospital.

The main function of the health record department in a hospital or clinic,

in this context, is as a service area, that is, medical records should be

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 produced for patient care at all times and as quickly as possible. Also,
discharge summaries and letters must be processed so that people
outside the hospital may be informed of the patient's progress and their
continued management after discharge.

3. Evaluation of patient care

In any setting in which an individual puts the responsibility for their

health and well-being into the hands of others, there should be some
mechanism that enables evaluation of the standard of care being given.
In some countries, hospital medicine is evaluated by an 'accreditation'
system. Surveys of each hospital are made and hospitals given
'accreditation' by a Board for a limited number of years, depending on
the standard which they reach. Also, in some countries, the health
record services of a hospital must meet predetermined standards.
Accreditation by this Board leads to increased status and is necessary
for acceptance of post-graduate trainees in many areas.

Other methods of evaluation of patient care in hospitals include:

a) Patient care committee - meets regularly and may review samples

of records and evaluate the standard of care recorded.

b) Peer review - Doctors of a service may evaluate the work of each

other and the unit through the records.

c) Hospital administrative committee - may evaluate the standard of

care in a particular ward or by a particular physician or surgeon.

d) Statistics - derived from records may also be used in assessment

of standards. This may be within the hospital, for example,
evaluating the infection rate in a particular ward or for a particular
operation or between clinics, hospitals, states or countries, in
which case the statistics are used by Government Departments
such as the Department of Public Health, Bureaus of Census and
Statistics or non-government organizations such as the World
Health Organization. In most countries the Department of Public
Health also requires notification of communicable diseases, such
as tuberculosis, cholera, hepatitis, etc.

4. Medical-Legal

Here, the main use of the record is as evidence of unbiased opinion of

a patient's condition, history and prognosis, all assessed at a time when
there was no thought of court action, and therefore extremely valuable.
It is used both in and outside the court for settlement of such disputes

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 as:

 assessing extent of injury in accident cases

 establishing negligence or otherwise of the health professional or

hospital in the treatment of a patient.

This assists in protecting the legal interests of the patient, hospital, and
health professional.

5. Statistical purposes

Statistics are collected in hospitals, clinics and in primary health care

centres. They may be used to tabulate numbers of diseases, surgical
procedures and incidence of recovery after certain treatments; to
assess areas which the hospital or clinic serves by collecting
demographic details; or for public health or epidemiology. They are
also used in planning for future development.

6. Research and education

In the past, health records have been mainly used in medical research,
but demographic and epidemiological information contained in the
record is more often used today for administrative and other public
health research.

Analyses of the types of people, together with studies of the types of

diagnosed illnesses within the hospital, a particular ward or clinic, are
essential for planning future services and equipment. The turnover rate
of patients is an indication of the numbers of staff required in all
departments. The workflow of the hospital or clinic can be analysed
once it is recorded in the medical record as it is added to by different
health professionals involved in the patient's care. All this information
shows the efficiency or otherwise of health planning and communication
systems.

7. Historical purposes

The record acts as a sample of the type of patient care and method of
treatment used at a particular point in time.

C. USES OF THE HEALTH RECORD

The uses of the health record can be divided into personal and impersonal
use depending on whether the user of the record is viewing the patient as a
'person' or as a 'case'. For example, the statistical, research and historical

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 uses are usually impersonal, the name of the patient is not important.

In other cases the use is patient-oriented. When a record is to be used in a

"PERSONAL" way; AN AUTHORIZATION FOR RELEASE OF
INFORMATION MUST BE OBTAINED FROM THE PATIENT, unless there
is a legal obligation to provide information. The information compiled in the
record is private and privileged and given to the health professional in
complete confidence. This trusting relationship between health professionals
and the patient must not be broken by revealing the contents of the health
record to unauthorized persons.

In IMPERSONAL uses, however, WHERE THE NAME OF THE PATIENT

IS NOT REVEALED, authorization is not usually necessary. It is usual to
obtain the consent of the health professional in charge of the patient before
allowing a record to be used for research. But remember that consideration
must always be given to the patient's rights in any release of information.

D VALUE OF THE HEALTH RECORD

An accurate and complete health record is of value:

1. to the patient
2. to the hospital, clinic, or other health facility
3. to the doctor and other health professionals
4. for research, statistics and teaching
5. for patient billing.

1. The patient

As the health record contains a complete report of a patient's illness

and results of treatment, it is of great value to the patient for -

a) future care for the same or other illnesses

b) informing them (by giving access) of their care and treatment, and

c) as a legal document to support claims for injury, or malpractice.

2. The hospital, clinic or other health facility

The health record may be used by the health facility to evaluate the
standard of care rendered by staff and the end results of treatment. If
adequate records are not kept, the facility cannot justify the results of
treatment. The health record is also of value to the facility for

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 medico-legal purposes.

3. The doctor and other health professionals

The health record is of value to all health professionals caring for a

patient. The patient may have been treated by them previously or by
other health professionals. The health record enables pertinent clinical,
social or other relevant information to be readily available for continuing
patient care. In addition the health record is of value for review of
certain diseases, treatment and response to treatment.

4. For medical research, statistics and teaching

In scientific research the health record is a major tool. The information

within a health record supplies a practical and reliable source of
material for the advancement of medical science. This information is
also valuable in the collection of statistics on health care and the
incidence of diseases, and for teaching future health professionals.

5. For patient billing

Without the information within a health record, payment for services

could not be justified. Often the health insurance agencies require
supporting evidence for claims - this evidence is found in the health
record.