The medical record is a powerful tool that allows the treating physician to track the patient’s medical history and identify problems or patterns that may help determine the course of health care.
The primary purpose of the medical record is to enable physicians to provide quality health care to their patients. It is a living document that tells the story of the patient and facilitates each encounter they have with health professionals involved in their care. Most importantly, however, they will contribute to comprehensive and high-quality care for patients by optimizing the use of resources, improving efficiency and coordination in team-based and interprofessional settings, and facilitating research.
This is achieved in the following ways: Quality of care: Medical records contribute to consistency and quality in patient care by providing a detailed description of patients’ health status and a rationale for treatment decisions. Continuity of care: Medical records may be used by several health practitioners.
The record allows other health care providers to access quickly and understand the patient’s past and current health status. Assessment of care.
Evidence of care: Medical records are legal documents and may provide significant evidence in regulatory, civil, criminal, or administrative matters when the patient care provided by a physician is questioned.
The legal requirements for medical records are set out in the Ontario Regulations made under the Medicine Act, 1991.
There is usually confusion within health information management industry as who actually has original ownership over the original record? patient or Physician?
Most would assume that the patient has the ownership of the record. However, this is not entirely the case. The Physical medical record actually belongs to the physician who created it and the facility in which the record was created.
The information gathered within the original medical record is owned by the patient. This is why patients are allowed a COPY of their medical record.
Every healthcare family is required by Law to maintain the original medical record of patient that receives care and must safeguard it from loss, damage, alteration and unauthorized use.
Although the original medical record is the property of the physician office who created it but patients have a right of access to their personal health information including any information that has been indicated as confidential unless an exception applies under section 52 of PHIPA (Personal Health Information Protection Act).