Medical RecordsIn this article, I do not post any health problems but about Medical Records. Why medical records so important for patients?

Yes.. because they are very useful for your re-visit, further treatment like operation, insurance needs, long medications, medical check-up, research purpose and many others.

Medical records is also important for legal purposes if sometime happen mal practice or police investigations as evidences on the court. The patients have a right for hard copy of their medical records.

Medical Records must contain many aspects such as:

1. Vital Signs

This is a part of Nurse’s job in Hospital or Clinic. Vital signs like blood pressure test, temperature level, pulse rate and respiratory test must be recorded as an input for the Doctor/Specialist.

2. Patient Data

To fill all data in medical records, patient should write down the forms as provided by Front Officer or Nurse. You must write base of the fact and do not manipulate it. Insurance company also need this information to get claim.

3. Patient’s History

Beside Doctor gets data from patient’s explanation, she or he gets also from physical examination. This medical notes are very important for another Doctor if someday you do not see him/her anymore.

4. Medical Progress Notes

Every little progress made from patient’s condition will be evaluated by Doctor’s team to set further steps of medication. Progress notes are can be from physical report, diagnostic notes or any complications.

5. Diagnostic Records

This part is also important like x-ray/CT-Scan/MRI images, Ultrasound result, EEG/ECG notes, Laboratory finding papers, etc.

Many Hospital will keep patient’s medical records from 5 years up to 25 years depend on the Government regulations. All Medical Staff up to Doctors must be responsible from broken data and avoid from anybody who have no authority. We also have responsibility from spreading medical patient data to public consumptions.

Sometimes, we have celebrity patients. Their medical records is strongly prohibited to public or mass media consumptions. This is real source for showbiz business to get spectacular news on the television or newspaper. We are to be careful if handling this matters.

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