Given the number of possible users, medical records can be very comprehensive and lengthy. In your role as medical assistant in a physician's office, the medical records you have seen do not have the kinds of detailed information that can be on the medical record of a hospitalized patient.
You wonder if you and your colleagues are missing important information that might help you better care for your patients.
What do you think are the pros and cons of having many users of medical records or having few users of medical records?
Oddly, I had a great deal of experience fighting over medical records both personally and professionally. Here is the experience I hope I can pass on for good measure:
Information gathering and analysis has been central to the effective delivery of healthcare. Most of the information generated in healthcare organizations is centered on the patient, and such information about individual patients are kept in confidential records known as medical records.
The information contained in these records include the patient details (such as name, sex, date of birth, occupation and address), the patient's medical history and any other relevant history, and a complete report of each event with the patient, from signs and symptoms when first presenting, through diagnosis and investigations to treatment and outcome. Other relevant information and documentation also need to be added.
For a long while, healthcare organizations have kept paper-based records but they have their shortcomings, some of which include:
? An increasingly mobile society ...