Kinds of Medical Records

medical recordsYour healthcare providers have created a whole host of medical records about you. You may want to obtain your own records because you are changing physicians or you want to be informed about your health care and condition.

Standards govern the creation, content, and retention of records. The Joint Commission standards provide a national framework for medical record content in facilities that are Joint Commission-accredited. Requirements for record keeping may be specified by each state through the standards of professional boards (Board of Medical Examiners, Board of Nursing, and so on), and by the federal government through OBRA (Omnibus Budget Reconciliation Act) which governs the structure of nursing homes.
While the hospital, nursing home, rehabilitation center, or other healthcare provider owns the physical medical record, the patient is entitled to the information contained within the record and has the right to receive copies of those records.

Types of medical records

• hospitals and emergency rooms records,
• emergency medical services records (ambulance or medical intensive care unit/MICU),
• records of physicians and specialists
• outpatient imaging (x-rays, MRI scans, CT scans, and so forth),
• any outpatient labs where blood work or other tests (EMG, EKG, and so forth) were done,
• inpatient and outpatient rehabilitation records including physical therapy, occupational therapy, and so forth,
• outpatient pain treatment centers,
• pathology specimens and reports,
• billing records,
• visiting nurse home care records,
• mental health, substance abuse records and HIV records,
• assisted living and nursing home records,
• employment physicals,
• fetal monitoring strips’
• videotapes of procedures,
• pathology or laboratory work that was referred to an outside source,
• drugstore pharmaceutical records,
• inpatient pharmacy profiles,
• inpatient narcotic control records,
• labor and delivery, operating room, emergency room, radiology, and laboratory logs,
• communication books used by nursing shifts to report to each other,
• insurance companies records,
• risk management reports or incident reports if there is an unusual occurrence.

Original x-ray films or copies of the films may be obtained. Generally, original films are only given to the patient. Copies may be of poor quality, but unless the original film is subpoenaed, the healthcare facility may not release the original. Always request the reports that accompany these films.

CT and MRI results may be stored on computer disks. Echocardiogram, angiogram, and ultrasound data may be kept on tape. Again, always request the reports that describe these films. They may be kept in an outpatient department or radiology center, not the main hospital medical records department. Mammogram reports should also have an accompanying history and physical or intake sheet. The form filled out to request the test may also contain important data about the justification for the study. This request form is not usually a permanent part of the medical record and possibly can be retrieved from the radiology department.

Medical procedures or surgeries are occasionally videotaped or photographed. Contact the healthcare facility and ask which department stores these images. Start with the director of the medical records department. He or she can direct you to the appropriate department that maintains this information whether it be Surgery or otherwise.

Emergency medical transport services records are sometimes not found in the emergency room record if hospital protocol dictates that they are not maintained as part of the records. Requests for these records need to be made to the specific service that rendered the care.

Special authorizations may be required for particularly sensitive information such as drug rehabilitation and psychiatric treatment. HIV testing may be kept apart from the record and needs to be specifically requested. Special authorizations may be required to obtain this information. In some instances psychiatric facilities require the patient to sign a special authorization in order to release records.

Modified from Obtaining and Organizing Medical Records, Patricia Iyer, MSN, RN, LNCC and Jane Barone, BS, RN, LNCC in Patricia Iyer and Barbara Levin, Editors, Medical Legal Aspects of Medical Records, Second Edition, Lawyers and Judges Publishing Company, 2010

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