Monday, 7 January 2013

General Information About Personal Medical Record

By Maryellen Lamb


The various documents that include details about the medical history of an individual are known as a personal medical record. These may be put together by health professionals or individuals themselves. Whatever the case, the info is considered private and personal. Often the records include a history of health problems, medications, treatments and more. This data, whether on paper or in electronic databases, can be request by the individual. There are health laws in place that require these records to be made available within 30 days of requests.

The files are meant to include all details. They are made available to health professionals so that these individuals can serve patients to their best ability. This knowledge of a patient can give professionals an idea on how to prevent or treat issues. These records might also have information about allergies and medication, which can keep harmful or non-effective treatments from being applied. The info is particularly important in cases of emergency when an individual may not be able to provide professionals with the facts they need.

Records have more than info about past illnesses, injuries, allergies, family health and medical treatments. They also include contact information and names of all physicians who have treated the patient, insurance plan details and lab results. This data is important when it comes to offering proper service.

All of the data included in these files is considered personal and sensitive. Because of this, a high level of privacy is expected with handling records. There are both ethical and legal issues related to accessing and maintaining these files. The info included in such records, in the majority of jurisdictions, is considered the property of a patient and no one else. However, laws regarding ownership and keeping of the files differ by country.

Medical history is referred to as a longitudinal record of what has occurred to a patient, in terms of health, since they were born. It includes major illnesses, growth landmarks, minor illnesses, diseases and more. This allows professionals to get a better understanding of the past of a patient so that they can help them in the present time or to prevent future problems. Subsets of the term: development history, growth chart, habits, social history, allergies, surgical history, medications, immunization history, family history and obstetric history.

In these records there are medical encounters that include discrete summaries of health history as documented by nurse practitioners, physicians or physician assistants. Each of these encounters typically includes a few elements. Some examples of aspects found in encounters: chief complaint, history of the current illness, physical exams, and assessment and plan.

People might choose to have their own records, though they may not be as detailed as those made by the professionals. In either case, having this important info available is ideal, especially for patients who suffer with many health problems. A number of computer programs are available that can aid in filing and organizing such info, but privacy should be a concern and priority.

The personal medical record of an individual includes files that have all of the info related to health care of the patient. The info should be private. Although it is available to health care professionals to allow them to offer the best possible care.




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