A Provider’s Perspective on Medical Records

What is a medical record?

The purpose of a medical record is to allow health care providers access to a patient’s medical history and to provide informed and quality medical care for patients. The medical record serves as the central source of planning and directing patient care. Additionally, the medical record is used for documenting communication among a patient and a health care provider and other professionals contributing to the patient’s care. Medical records are used for a variety of reasons. It is used to document the medical interactions between a patient and a provider, and for medical references, billing and legal purposes.

Medical records contain a complete record of a patient’s key clinical information and past medical history. Examples of the type of information in medical records include patient demographics, vital signs, diagnoses, medications, treatment plans, clinician progress notes, immunization dates, allergies, images, procedures, and laboratory and test results. The physical medical records belong to the physician or provider who created it and the facility where the record was created. Even though the physical medical record belongs to the physician, the information contained within the original medical record is owned by the patient. Therefore, patients are allowed a copy of their medical record, but not the original document.

Importance of A Medical Record To A Physician

Due to all the pertinent medical information and data compiled into a patient’s medical record, it is very important for physicians to use the data to care for patients. A physician uses a patient’s medical record to familiarize themselves with a patient’s past health history to continue care in new patients. Clinical notes made in the medical record can also assist providers in following the treatment decisions and plans for current patients under their care. It is vital for a physician to know what allergies patients have so that it can help direct appropriate treatment options and plans in addressing patient illnesses.

Understanding how a physician uses a medical chart to care for patients is a significant point for patients. This is why it is vital that patients have copies of their medical records so that the care provided by physicians is not hindered by a lack of medical history for that particular patient.

Order Medical Records can help!

If you’re a patient and would like to get copies of your medical records, Order Medical Records is here to assist you. We make it our business to obtain copies of your medical records for you. Give us a call at 714 559-3071 today to get started!