What are the Medical Records?

What are Medical Records?

Medical records are documents that detail a patient’s medical history and personal information. These may take the form of electronic records, handwritten notes or print documents filed away in folders. 

 

A medical record includes personal information such as the patient’s name, date of birth, and contact details. This helps incorrectly identifying a patient and provides important contact information in the event of a medical emergency.

 

Your medical record also includes details about your medical conditions, medication history, and relevant family medical history. These include significant illnesses and treatments rendered, prescriptions, and discharge records. The information is kept confidential and is only used by healthcare professionals to make medical-related decisions. For example, doctors taking care of you would use the records to have a complete picture of your condition, such as previous adverse reactions to certain medications.

How are medical records used in a lawsuit?

From a medical-legal perspective, they contain a record of any provisional diagnoses, subsequent interventions, and treatment provided. This information is useful in evaluating whether the care provided to you was up to standard. If you need your medical records for a lawsuit, you could request them from your healthcare provider. Alternatively, the attorney in charge of your case could also request them on your behalf.

 

Finally, more information is now shared over the network to allow healthcare professionals to have better access to their patients’ information. This sharing of information allows doctors and nurses to make medical decisions more safely. For instance, a doctor might learn of a patient’s adverse reaction to a treatment performed elsewhere based on shared information and avoid prescribing a similar treatment by mistake. However, a downside to this open sharing of information would be the potential for confidential patient information to be inadvertently leaked. 

 

To find out more about getting your medical records, see How Do I Get My Medical Records?