Health record
A medical record in paper or electronic format provides a written account of a patient’s medical history, containing information about diagnosis, treatment, chronological progress notes and discharged recommendations. A whole raft of legislation, standards and guidance on what has become known as Information Governance has been produced in the last few years to cover issues of access, confidentiality and disclosure.
The Health and Social Care Act 2008 established the National Information Governance Board for Health and Social Care (NIGB) as the body with statutory duty to oversee Information Governance. One of its functions confidentiality to be set aside in specific circumstances.
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases. This repository of information about a single patient is generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient.
The primary patient record is the record that is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions.
The secondary patient record is a record that is derived from the primary record and contains selected data elements to aid non clinical persons in supporting, evaluating and advancing patient care. Patient care support refers to administration, regulation, and payment functions.
The relevance of health records:
- Allow a subsequent caregiver to understand the patient’s condition and the basis for the current investigations or treatments.
- act as evidence: if your care is later questioned, it shows events as they happened
- Provide a method of communicating with other team members.
- satisfy legal and ethical obligations: medical regulatory authority (College), hospital, and legislative requirements for clear and legible records
- Facilitate good care.
