Medical record: Difference between revisions
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A '''medical record''' is a compilation of [[medical data]] relating to a [[patient]]. Although medical records are held by the [[physician]] they are the [[legal property]] of the patient. |
A '''medical record''' is a compilation of [[medical data]] relating to a [[patient]]. Although medical records are held by the [[physician]] they are the [[legal property]] of the patient. |
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==Divisions of the medical record== |
==Divisions of the medical record== |
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Information regarding the patient which is not medical in nature. It is often identifying information to locate the patient including identifying numbers, addresses and contact numbers. It may contain information about race and religion as well as workplace and type of work information. |
Information regarding the patient which is not medical in nature. It is often identifying information to locate the patient including identifying numbers, addresses and contact numbers. It may contain information about race and religion as well as workplace and type of work information. |
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===Medical |
===Medical history=== |
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The medical history is a [[longitudinal]] record of what has happened to the patient since birth. It chronicles [[diseases]], major and minor [[illness]]es as well as [[growth landmarks]]. It gives the [[clinician]] a feel for what has come before. Often it may give clues to current [[disease state]]s. |
The medical history is a [[longitudinal]] record of what has happened to the patient since birth. It chronicles [[diseases]], major and minor [[illness]]es as well as [[growth landmarks]]. It gives the [[clinician]] a feel for what has come before. Often it may give clues to current [[disease state]]s. |
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The surgical history is often a subset of the medical history. It is a chronicle of [[surgery]] performed for the patient. It may have [[operative report]]s, the detailed narrative of what the [[surgeon]] did. |
The surgical history is often a subset of the medical history. It is a chronicle of [[surgery]] performed for the patient. It may have [[operative report]]s, the detailed narrative of what the [[surgeon]] did. |
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====Family |
====Family history==== |
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The [[family]] history is another [[subset]] of the medical history. It lists the health status ancestors as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It is a valuable asset in predicting some outcomes for the patient. |
The [[family]] history is another [[subset]] of the medical history. It lists the health status ancestors as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It is a valuable asset in predicting some outcomes for the patient. |
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====Social |
====Social history==== |
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The social history is a chronicle of human interactions. It tells of the [[relationship]]s of the patient, the careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of [[community]] support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. |
The social history is a chronicle of human interactions. It tells of the [[relationship]]s of the patient, the careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of [[community]] support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. |
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====Vital signs==== |
====Vital signs==== |
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There are usually four; however, lately pain measurement has become a fifth. |
There are usually four; however, lately pain measurement has become a fifth. |
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=====Temperature===== |
=====Temperature===== |
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Body temperature is recorded in degrees of temperature. In [[Fahrenheit]] it is 98.6. That is an average temperature and body temperature varies with time of day and body conditions. Elevations in temperature above 100 degrees F are considered to be [[fever]]. Prolonged elevated temperatures or [[Hyperthermia]] are incompatible with life. Prolonged depressions in temperature [[hypothermia]] are likewise not compatible with life. The body functions within a rather narrow range so that essential enzymatic reactions can occur. The temperature can be taken as [[oral temperature]] by putting a [[thermometer]] under the tongue for 3-5 minutes. When that cannot be done or the patient cannot cooperate with holding the thermometer, a [[rectal temperture]] can be taken by inserting the thermometer into the rectum for 3-5 minutes. During some operative procedures [[thermosensitive material]] can be placed on the [[forehead]] to give general temperature ranges. Temperatures can be measureed using a special [[thermocouple]] to measure temperature at the eardrum, or [[tympanic membrane]]. Temperature taken rectally is sometimes called [[core temperature]] and is considered more accurate than other means. |
Body temperature is recorded in degrees of temperature. In [[Fahrenheit]] it is 98.6. That is an average temperature and body temperature varies with time of day and body conditions. Elevations in temperature above 100 degrees F are considered to be [[fever]]. Prolonged elevated temperatures or [[Hyperthermia]] are incompatible with life. Prolonged depressions in temperature [[hypothermia]] are likewise not compatible with life. The body functions within a rather narrow range so that essential enzymatic reactions can occur. The temperature can be taken as [[oral temperature]] by putting a [[thermometer]] under the tongue for 3-5 minutes. When that cannot be done or the patient cannot cooperate with holding the thermometer, a [[rectal temperture]] can be taken by inserting the thermometer into the rectum for 3-5 minutes. During some operative procedures [[thermosensitive material]] can be placed on the [[forehead]] to give general temperature ranges. Temperatures can be measureed using a special [[thermocouple]] to measure temperature at the eardrum, or [[tympanic membrane]]. Temperature taken rectally is sometimes called [[core temperature]] and is considered more accurate than other means. |
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=====Blood pressure===== |
=====Blood pressure===== |
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The blood pressure is recorded as two readings, a high [[systolic]] pressure which is the maximal contraction of the heart and the lower [[diastolic]] or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm. The [[blood pressure]] cuff which fits around the arm The difference between the systolic and diastolic pressure is called the [[pulse pressure]]. The measurement of these pressures is now usually done with an [[aneroid]] [[sphygmomanometer]]. The classic measurement device is a [[Mercury (element)|mercury]] sphygmomanometer, using a column of mercury measured off in [[inches]] or [[millimeters]]. In the United States the common form is millimeters of mercury. A state of [[hypertension]] exists when the systolic number is persistently over 140 mmHg. Low blood pressure is [[hypotension]]. Blood pressures are also taken at other portions of the extremities. These pressures are called [[segmental blood pressure]]s and are used to evaluate blockage or [[arterial occlusion]] in a [[limb]]. |
The blood pressure is recorded as two readings, a high [[systolic]] pressure which is the maximal contraction of the heart and the lower [[diastolic]] or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm. The [[blood pressure]] cuff which fits around the arm The difference between the systolic and diastolic pressure is called the [[pulse pressure]]. The measurement of these pressures is now usually done with an [[aneroid]] [[sphygmomanometer]]. The classic measurement device is a [[Mercury (element)|mercury]] sphygmomanometer, using a column of mercury measured off in [[inches]] or [[millimeters]]. In the United States the common form is millimeters of mercury. A state of [[hypertension]] exists when the systolic number is persistently over 140 mmHg. Low blood pressure is [[hypotension]]. Blood pressures are also taken at other portions of the extremities. These pressures are called [[segmental blood pressure]]s and are used to evaluate blockage or [[arterial occlusion]] in a [[limb]]. |
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=====Pulse===== |
=====Pulse===== |
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The pulse is the physical expansion of the artery. It is usually measured either at the wrist or the ankle. The pulse commonly is taken as a [[radial pulse]] at the wrist. It is recorded as beats per minute. Sometimes the pulse cannot be taken at the wrist and is taken beneath the arm ([[brachial pulse]]), at the neck against the [[carotid artery]] ([[carotid pulse]]), behind the knee ([[popliteal pulse]]), or in the foot [[dorsalis pedis pulse]] or [[posterior tibial pulse]]. The pulse can also be measured by listening directly to the [[heart]] or by using a [[stethyscope]] to augment the sounds. |
The pulse is the physical expansion of the artery. It is usually measured either at the wrist or the ankle. The pulse commonly is taken as a [[radial pulse]] at the wrist. It is recorded as beats per minute. Sometimes the pulse cannot be taken at the wrist and is taken beneath the arm ([[brachial pulse]]), at the neck against the [[carotid artery]] ([[carotid pulse]]), behind the knee ([[popliteal pulse]]), or in the foot [[dorsalis pedis pulse]] or [[posterior tibial pulse]]. The pulse can also be measured by listening directly to the [[heart]] or by using a [[stethyscope]] to augment the sounds. |
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=====Height===== |
=====Height===== |
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Height is the [[anthropometric]] [[longitudinal]] growth of an individual. A [[statiometer]] is the device used to measure height although often a [[height stick]] is more frequently used for [[vertical]] measurement of adults or children older than 2. The patient is asked to stand [[barefoot]]. Height declines during the day because of compression of the [[intervertebral disc]]s. In the United States and England height is measured in [[feet]] and [[inches]]. In other countries using the metric system in [[meter]]s. Children under age 2 are measured [[horizontally]]. |
Height is the [[anthropometric]] [[longitudinal]] growth of an individual. A [[statiometer]] is the device used to measure height although often a [[height stick]] is more frequently used for [[vertical]] measurement of adults or children older than 2. The patient is asked to stand [[barefoot]]. Height declines during the day because of compression of the [[intervertebral disc]]s. In the United States and England height is measured in [[feet]] and [[inches]]. In other countries using the metric system in [[meter]]s. Children under age 2 are measured [[horizontally]]. |
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=====Weight===== |
=====Weight===== |
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[[Weight]] is the antropometric [[mass]] of an individual. A [[scale]] is used to measure weight. The English system uses [[pound]]s and [[ounce]]s; the SI system uses [[kilogram]]s. [[Body mass index]] or BMI is used to calculate the relationship between healthy height and weight and [[obesity]] or being overweight or underweight. |
[[Weight]] is the antropometric [[mass]] of an individual. A [[scale]] is used to measure weight. The English system uses [[pound]]s and [[ounce]]s; the SI system uses [[kilogram]]s. [[Body mass index]] or BMI is used to calculate the relationship between healthy height and weight and [[obesity]] or being overweight or underweight. |
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=====Pain===== |
=====Pain===== |
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Because of the importance of [[pain]] to the overall wellness of the patient, [[subjective]] measurement is considered to be a vital sign. Clinically pain is measured using a [[FACES]] scale which is a series of faces from -0- or no pain at all showing a normal happy face to -5- which is the worst pain ever experienced by the patient. There is also an [[analog]] scale from 0 -10 where -0- represents no pain and -10- the worst pain ever experienced by the patient. It is important to allow patients to make their own choices on a pain scale. Often physicians and health care workers understate patient pain. |
Because of the importance of [[pain]] to the overall wellness of the patient, [[subjective]] measurement is considered to be a vital sign. Clinically pain is measured using a [[FACES]] scale which is a series of faces from -0- or no pain at all showing a normal happy face to -5- which is the worst pain ever experienced by the patient. There is also an [[analog]] scale from 0 -10 where -0- represents no pain and -10- the worst pain ever experienced by the patient. It is important to allow patients to make their own choices on a pain scale. Often physicians and health care workers understate patient pain. |
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====HEENT==== |
====HEENT==== |
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Head, eyes, ears, nose and throat. This part of the exam is about the head. |
Head, eyes, ears, nose and throat. This part of the exam is about the head. |
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=====Head===== |
=====Head===== |
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An examination of the [[head (anatomy)|head]] looks first for [[symmetry]]. A quick check of the hair to see if the hair growth is [[receding]] or there is loss of hair, [[alopecia]]. A quick check of the skin will tell if there are marks such as [[hemangioma]] or strawberry marks or changes to the skin. Dark spots on the skin, [[nevi]] are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed. |
An examination of the [[head (anatomy)|head]] looks first for [[symmetry]]. A quick check of the hair to see if the hair growth is [[receding]] or there is loss of hair, [[alopecia]]. A quick check of the skin will tell if there are marks such as [[hemangioma]] or strawberry marks or changes to the skin. Dark spots on the skin, [[nevi]] are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed. |
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After skin and hair are checked the neck and throat are palpated for [[lymph nodes]]. |
After skin and hair are checked the neck and throat are palpated for [[lymph nodes]]. |
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==See also== |
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*[[Electronic medical record]] |
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*[[Electronic Health Record]] |
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The ear exam is called |
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===Progress notes=== |
===Progress notes=== |
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===Test results=== |
===Test results=== |
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====Laboratory==== |
====Laboratory==== |
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====Radiographic==== |
====Radiographic==== |
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====Other test results==== |
====Other test results==== |
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==Medical record entries== |
==Medical record entries== |
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==Custody of the medical record== |
==Custody of the medical record== |
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==Moving a medical record== |
==Moving a medical record== |
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==Destroying a medical record== |
==Destroying a medical record== |
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==The new medical record== |
==The new medical record== |
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--> |
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[[Category:Medical informatics]] |
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==Organizations dealing with medical records== |
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[[ja:診療録]] |
[[ja:診療録]] |
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Revision as of 19:17, 23 April 2005
 | This article provides insufficient context for those unfamiliar with the subject. |
A medical record is a compilation of medical data relating to a patient. Although medical records are held by the physician they are the legal property of the patient.
Divisions of the medical record
Information regarding the patient which is not medical in nature. It is often identifying information to locate the patient including identifying numbers, addresses and contact numbers. It may contain information about race and religion as well as workplace and type of work information.
Medical history
The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses as well as growth landmarks. It gives the clinician a feel for what has come before. Often it may give clues to current disease states.
Surgical history
The surgical history is often a subset of the medical history. It is a chronicle of surgery performed for the patient. It may have operative reports, the detailed narrative of what the surgeon did.
Family history
The family history is another subset of the medical history. It lists the health status ancestors as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It is a valuable asset in predicting some outcomes for the patient.
Social history
The social history is a chronicle of human interactions. It tells of the relationships of the patient, the careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss.
Habits
Often this part of the history can be part of the social history. It more often a record of such things as tobacco use, alcohol intake, recreational drug use, exercise or diet. It can be about more intimate things such as sexual habits and sexual preferences. It often helps to fill in information about patients.
Physical exam
The physical examination is the actual recordings of observations of the patient. Some specialties have longer or more detailed parts of physical examinations. Generally they proceed from head to toe.
Vital signs
There are usually four; however, lately pain measurement has become a fifth.
Temperature
Body temperature is recorded in degrees of temperature. In Fahrenheit it is 98.6. That is an average temperature and body temperature varies with time of day and body conditions. Elevations in temperature above 100 degrees F are considered to be fever. Prolonged elevated temperatures or Hyperthermia are incompatible with life. Prolonged depressions in temperature hypothermia are likewise not compatible with life. The body functions within a rather narrow range so that essential enzymatic reactions can occur. The temperature can be taken as oral temperature by putting a thermometer under the tongue for 3-5 minutes. When that cannot be done or the patient cannot cooperate with holding the thermometer, a rectal temperture can be taken by inserting the thermometer into the rectum for 3-5 minutes. During some operative procedures thermosensitive material can be placed on the forehead to give general temperature ranges. Temperatures can be measureed using a special thermocouple to measure temperature at the eardrum, or tympanic membrane. Temperature taken rectally is sometimes called core temperature and is considered more accurate than other means.
Blood pressure
The blood pressure is recorded as two readings, a high systolic pressure which is the maximal contraction of the heart and the lower diastolic or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm. The blood pressure cuff which fits around the arm The difference between the systolic and diastolic pressure is called the pulse pressure. The measurement of these pressures is now usually done with an aneroid sphygmomanometer. The classic measurement device is a mercury sphygmomanometer, using a column of mercury measured off in inches or millimeters. In the United States the common form is millimeters of mercury. A state of hypertension exists when the systolic number is persistently over 140 mmHg. Low blood pressure is hypotension. Blood pressures are also taken at other portions of the extremities. These pressures are called segmental blood pressures and are used to evaluate blockage or arterial occlusion in a limb.
Pulse
The pulse is the physical expansion of the artery. It is usually measured either at the wrist or the ankle. The pulse commonly is taken as a radial pulse at the wrist. It is recorded as beats per minute. Sometimes the pulse cannot be taken at the wrist and is taken beneath the arm (brachial pulse), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal pulse), or in the foot dorsalis pedis pulse or posterior tibial pulse. The pulse can also be measured by listening directly to the heart or by using a stethyscope to augment the sounds.
Height
Height is the anthropometric longitudinal growth of an individual. A statiometer is the device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2. The patient is asked to stand barefoot. Height declines during the day because of compression of the intervertebral discs. In the United States and England height is measured in feet and inches. In other countries using the metric system in meters. Children under age 2 are measured horizontally.
Weight
Weight is the antropometric mass of an individual. A scale is used to measure weight. The English system uses pounds and ounces; the SI system uses kilograms. Body mass index or BMI is used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.
Pain
Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered to be a vital sign. Clinically pain is measured using a FACES scale which is a series of faces from -0- or no pain at all showing a normal happy face to -5- which is the worst pain ever experienced by the patient. There is also an analog scale from 0 -10 where -0- represents no pain and -10- the worst pain ever experienced by the patient. It is important to allow patients to make their own choices on a pain scale. Often physicians and health care workers understate patient pain.
HEENT
Head, eyes, ears, nose and throat. This part of the exam is about the head.
Head
An examination of the head looks first for symmetry. A quick check of the hair to see if the hair growth is receding or there is loss of hair, alopecia. A quick check of the skin will tell if there are marks such as hemangioma or strawberry marks or changes to the skin. Dark spots on the skin, nevi are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed.
After skin and hair are checked the neck and throat are palpated for lymph nodes.
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