Your Health Record – What is it?

Medical records can be used in legal proceedings.  

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Egyptian Medicine www.newscientist.com

Health is the absence of disease or abnormality caused by organic, environmental, or congenital problems. To remain healthy, you will be free of outside physical, social, and other problems that could lead to disease. When/if your health becomes challenged and if you seek medical care for that challenge, you will begin to generate a health record.

Ancient Egyptian Papyrus Smith Papyrus – Ebers Papyrus www.crystalinks.com

Your medical/health record belongs to you and chronicles the health care you have received, where ever you have received it.

The Ancient Greeks recorded medical works in the form of case histories. These case histories included the advice given to patients about diet, statements of successful cures, lessons for surgeons and even autopsies.  Record keeping became essential as the practice of keeping records was revived in the fourteenth and fifteenth centuries.  By the sixteenth century there was such an interest in scholars focusing on natural specifics and the practice of using observation to collect knowledge about the natural world that collections of cases were published.

The Egyptians and Romans also kept medical records. Greek and Roman medical records tend to overlap as they both created an efficient recording system more than 2,000 years ago.  The Greek and Romans has less emphasis on astrology and magic as they used a more scientific thought process while describing a patient’s physical and mental histories, although they still viewed the Gods as the deciders of one’s future.

Egyptian Medical Records on papyrus www.lauragonzales.co.uk

Ancient Mesopotamia, made of the modern countries of Syria, Turkey, parts of Iran, and Iraq, understood the importance of medical records.  These records also would have contained information on astrology, astronomy, and spells as well as surgery, general medicine, and dentistry.

When more modern medical documentation began, the records of a patient’s stay in the hospital was usually a few lines in a ledger that gave the patient’s name, address, chief complaint (why he or she is at the hospital), doctor’s name, the amount that the patient paid for services, and perhaps a few lines describing the type of treatment the patient received.

By 1928, the American Medical Record Association (AMRA) was founded to promote standards for the accuracy and quality of patient care documentation. The name was later changed to American Health Information Management Association (AHIMA) to identify the changing roles for managing health information that no longer consists of the paper record.  Thus, the medical record evolved from a ledger to a multiform file which contains computer-generated data.

All medical professionals are required to document information into medical records.  Medical records are written records which concern your medical history, symptoms, chief complaint, diagnoses, laboratory, radiology, and surgery results, treatments, procedures, medications, treatment plans, and the outcomes of treatments. Medical records can be used in legal proceedings.  www.nlm.nih.gov

Mayans Report Smallpox spread to Yucatan Peninsula www.nlm.nih.govSome of the first notations in your health record will be data (smallest elements or units of facts or observations) which will be items, observations, or raw facts. The term data (datum = singular form) also refers to a collection of these elements. Data will be facts that are related to your diagnosis and procedures performed as well as any factors that might affect your condition.

Health information can refer to the organized data, such as your blood pressure over a period of time, information on health trends of an entire nation, or it can be the summary of information about your entire experience with your physician. Health data is important for health care communication.

Health data is used by:

  • Hospital administrators when they need to make decisions about what services to offer and how best to serve the community in which they are located.
  • Lawyers will use health data to demonstrate the extent of injuries suffered by a client.
  • Payers, such as insurance companies, and Medicare will use health data to determine reimbursement to providers.
  • Government agencies, such as the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS), use health data to monitor disease.
Hippocrates fatchicksings.com

A personal health record (PHR) is your own copy of health information documenting your health care history and providing information on continuing patient care. A PHR can be either paper or computer-based. An individual owns his or her own health information which can be used for making health decisions. Some facilities may be hybrid with some areas using paper and others using computers.

During Hurricane Katrina, with the destruction of millions of health records, the practice of continuing patient care became nearly impossible. Clearly it was going to be necessary to find another way to maintain health records which could not be physically destroyed. Thus, the electronic medical/health record was born with the capability of health information moving with the patient.

Electronic Health Records (EHRs) are a computer-based information resource focusing on the total health of the patient while allowing access to patient information when and where needed. These records are safe and will only be shared with your permission. Health care is a shared effort. The EHR represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual. “EHRs are designed to be accessed by all people involved in the patient’s care—including the patients themselves. Indeed, that is an explicit expectation in the Stage 1 definition of “meaningful use” of EHRs.” (Healthhit.gov, 2017)

An EHR results from computer-based data collection. Documentation can be made in a laptop within a patient’s room, tablets, hand held devises, etc. which gives almost instant up to date knowledge of what is going on with a patient.

Virtual Medical Papyrus Unfurls at NLM The NIH Record nihrecord.nih.gov

The EHR is used for patient care, as a legal document, for statistics, for coding, and performance improvement. These records are secure, point-of-care, patient centric, real-time information for clinicians. A fully useful EHR streamlines and automates medical care as it integrates patient history, demographics, list of current medications, allergies, patient problem lists, physician clinical notes, nurse’s progress notes and information from hospitalizations, patient’s medical history, family history, immunization status, records of hospitalizations, insurance information, and follow-up notes.

 

Your health information can be accessed by any healthcare provider you see. EHRs allow for efficient storage and retrieval of information.  Test results can be shared quickly and will keep you from having duplicate tests performed. With the use of EHRs, there is less chance of medical errors occurring.  With 400,000 reported preventable medical errors which are the third leading cause of death, behind heart disease and cancer.

The health world operates with the use of the health record which is quickly becoming the electronic health record.  Easy, shared access of important health information is the wave of the future.

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8 COMMENTS

  1. Your argument that these medical records help in the fight against medicare fraud is ludicrous. Since HIPAA’s enactment in August 1996 why has there been an INCREASE in medicare fraud?!? Last July there was a $1.3 BILLION fraud case by the F.B.I. and DOJ. Why’d they wait until it reached $1.3 Billion?!?!? What? They couldn’t figure out the FRAUD at . . . oh, I don’t know . . . at the $1.3 MILLION?!?!?!
    Here’s what they do . . . they plant a “whistle blower” into the network that they KNOW is defrauding medicare. The whistle blower, the mole, is there for a reason. The reason is to expose the case, file a whistle blower lawsuit as the “employee” who found it out. The DOJ and FBI already know what’s going on, i.e., fraud, but they want their inside whistle blower to wait.
    Why?
    Do you know what a RELATOR is?
    I bet you don’t.
    Do you know what a Qui Tam action is?
    I bet you don’t.
    Do you know what the False Claims Act is?
    I bet you don’t.
    A large medical corporation is defrauding the government. Those that work billing are in on the racket. They can be plants by operatives IN the U.S. government.
    Wait until the “fraud” is good and up there . . . $1.3 Billion is a NICE chunk ‘o change. Why? Because the whistle blower gets 10% of what the government collects.
    It’s a game Nurse Carol. You have no idea how it’s played.

  2. What utter bull crap. Anytime a government outfit wants YOUR information . . . they own you. HIPAA is irrelevant. The HIPAA band-aid placed on the severed juggler — absolutely worthless in other words. I took my rose colored glasses off a long time ago. I suggest you do the same. Anytime someone writes of the “law” . . . and the remedy as if that’s going to prevent violations . . . it’s laughable.
    There’s one word, and I’m going to bet you don’t even know what that one word is. Although you WROTE IT in your wonderful, feel good quote. Go back and re-read your last paragraph.
    Do you know what I’m referencing? <—————–that's a clue.
    Of course you don't know. <———————- that's another clue.
    Come on, you're smart.
    Here we go. HIPAA violation and sanctions are meaningless. The quote you wrote is WORTHLESS. Nothing but empty words, which do NOT protect a Patient. And it's because of one word they wrote into the law, which YOU QUOTE. Give up. Do you know?!?
    No one can prove someone "knowingly" violated HIPAA rights. The word is "KNOWINGLY."
    If the Patient finds out (they never do), and they file a claim, THEY (the claimant) has the legal burden to prove their claim of under HIPAA violation. The claimant has to PROVE the violation was . . . . . . . wait for it . . . . . . . wait for it . . . . . . . . done KNOWINGLY!
    LMMFGAO. So good luck with proving someone else's knowledge. All they have to say is "Gee, I didn't know." And they are scot free. They can put their hand on a stack of B-I-B-L-Es and swear an oath to all that is HOLY and just say "I didn't know." Even if they are LYING about "not knowing" {wink, wink}. PROVE THEY "KNOWINGLY" violated the Patient's medical records. OMIGOSH. Nurse Nancy such a gullible sort. Pity. AMA and ABA biggest cartels on U.S. soil.

  3. Johnny America,

    I could not agree more with the need for more far reaching penalties. Even if a medical worker accesses the records of someone that he or she is not involved in the care of, that is a breach of privacy and one can loose his or her job as well as face the penalties handed down by law.

    Carol

    • OH please . . . the HIPAA violation law is MEANINGLESS.
      Prove they KNOWINGLY violated the Patient’s privacy. “Even if a medical worker accesses the records . . . ”
      How would a Patient even realize that?!?!? Prove that “a medical worker accessed the records of someone that he/she was not involved in the care of,” for starters! Mighty tough words there Caroi, “that is a breach of privacy and one can loose his or her job as well as face the penalties handed down by law.”
      Yeah . . . but PROVE IT. And on top of that . . . prove it was KNOWINGLY!
      NOTHING has been handed down by law. A case needs to be adjudicated before anything can be “handed down” by law.
      The HIPAA law was written, and it is toothless. It’s the one word they put in to make the HIPAA law violations impotent: KNOWINGLY.

  4. Your healthcare records can and will be used against you in a court of law.
    Also, your mental health status, an OPINION, can be used to relegate you to second class citizen status.

    “Easy, shared access of important health information is the wave of the future.”

    That’s what scares me.

    So hackers can find people in positions of power and blackmail them. “If you do not vote for this law, we will reveal your scorching case of herpes to the constituency”.

    Or maybe scour and find mentally ill people to recruit for certain projects…

    • Johnny America, I can relate to what your concerns are here. Servers who carry medical health records have a great deal of security. As for the “can be used in court” statement: Health records have always been admissible in court proceeding as they are an account of what happens to a person. When reviewing a health record, mistakes in care, etc. can be found that may or may not help in the defense of someone (medical professional) who is being accused of malpractice. It is not permissible for a health record to be searched for issues such as you mentioned. Only those who are in direct contact with a patient can access a medical health record. You health records are protected by HIPPA:
      HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. HIPAA does the following:

      Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs;
      Reduces health care fraud and abuse;
      Mandates industry-wide standards for health care information on electronic billing and other processes; and
      Requires the protection and confidential handling of protected health information (http://www.dhcs.ca.gov)
      There are fines for illegally accessing health care information. Audits are performed to check for illegal access of patient files. the “Wrongful Disclosure Section”) of the Health Insurance Portability and Accountability Act (HIPAA). The section provides that any person who “knowingly and in violation of this part…obtains individually identifiable health information relating to an individual” is subject to a misdemeanor punishable by a fine of not more than $50,000 and/or imprisonment for not more than one year.
      Carol

    • Thank you for the reply. Good article and great follow up.

      It’s good they take security seriously, but having worked in IT, I know that nothing is bulletproof. I feel safe, but the powerful, important, or otherwise vulnerable were my concerns.

      For people with medical issues who travel outside their local doctors access, I can see these EHRs are very important to keep them healthy…

      Id like to see stiffer penalties, though I know that only goes so far in crime prevention.

      Thanks again, and keep up the good work!

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