Understanding Medical Records
A medical record is basically essential patient information that is required to provide the maximum medical care to a person in need of medical attention. When a person visits a doctor or hospital or any health care provider, a record is opened in their name to keep all the pertinent data related to their health and medical history. The physicians note down all the information about the patient that they obtain from their observation and diagnosis; they will also write down the tests performed, the results, the medicines and treatments administered. There will also be lab reports, surgery details, referral letters, discharge notes, etc. attached to a patient’s medical record. These records are stored and retrieved for further use; each time the person is examined by the same physician or several physicians, these records are needed to understand the conditions of the person and to determine the right kind of treatment to be administered.
In the past, the medical records were in the written or type written format, consisting of the doctors’ notes, lab reports, etc. They were filed and kept in cabinets for future use. But, modern technologies and the development of the Internet have made it possible to keep computerized files of the medical reports. Rather than writing down observations and treatment procedures, physicians and medical professionals now verbally dictate all the medical information regarding a patient. These are recorded and stored with the help of cassette based voice dictation systems or digital voice dictation systems. Later, these audio dictates are converted into typewritten format and stored digitally. Typically, it is the medical transcriptionists who do this conversion process known as medical transcription.
Typically, a medical record will contain the following elements:
- Name, age, and contact details of the patient
- Gender
- Blood type
- Dates and details of previous check-ups
- Dates and results of tests
- Current and previous diseases and conditions
- Details of current and previous medication
- Allergies
- History of family diseases
- Referrals
- Follow-up instructions
The contents of medical records widely vary depending on purpose and data included. The job of a medical transcriptionist is to transcribe various types of medical records. The records come as audio dictates from hospitals, clinics, labs, health care facilities, physicians’ offices, and other medical professionals. The medical transcriptionists transform these audio medical records into typewritten documents that are sent back to the sources from where they came. These medical records are kept in medical facilities for reference and future use. Some more information of medical records.
