What type of data primarily composes a medical chart?
Ideally, understanding the standard for accessing patient information also requires understanding the specific contents within a patient’s medical chart. Basically, medical charts have the patient’s past and active medical history. This includes medical conditions, immunizations, chronic and acute diseases, treatments, and testing results. In fact, the target goal behind a medical chart is to keep physicians informed on a patient’s medical well-being in order to support accurate diagnoses, treatments, and follow-ups, as well as the prevention of future disorders. As the world becomes more technologically advanced, so does the medical industry. In regards to patient information, the rise in EMRs and EHRs (electronic medical and health records) has helped the medical industry capture & organize real-time data in one’s chart including:
- Patient demographics: this includes the date of birth, race, age, gender, contact information, ethnicity, and preferred language, abiding by the Medicare measures for promoting interoperability.
- Medical visits: meaning second opinions, initial consultations, routine checkups, follow-up visits, and all procedures.
- Developmental history: this covers documents linked to developmental milestones such as emotional, social, cognitive, and motor development.
- Past and present medications
- Allergies, including foods, medications, etc.
- Active diagnoses/problems: diseases, chronic and acute conditions, disorders, etc.
- PMH or past medical history
- PSH or past surgical history
- Social history: which means occupation, marital status, and education. This also includes alcohol usage, smoking habits, sexual history, diet, and exercise habits.
- Family history: what diseases are present among family members? Best to watch out for the potential development of certain cancers, or other disorders such as diabetes, dementia, epilepsy, etc.
- Obstetric history: pregnancy outcomes, past pregnancies, and any and all complications.
- Immunizations and their respective dates: Examples of which include pediatric vaccines, pneumonia, influenza, shingles, and Covid-19 vaccines.
Other data inside a medical chart
On top of the wide array of the information listed above, medical charts often include far more details and information relevant to patient care, such as sections dedicated to various aspects of a unique patient’s care. Specifically, one can find information under categories such as:
- Plans and Assessments: This section contains diagnostic conclusions and the physician’s requested plan for treatment.
- Orders: This section contains specific procedural, imaging, and lab testing orders, as well as prescriptions, referral orders, and much more.
- Results: In turn, this section will contain the results of any such orders or plans and assessments, such as imaging reports and lab results electronically acquired from imaging interfaces or labs. Moreover, result information and documentation can be manually added or uploaded to a patient’s chart here.
- Vital Signs: This section records information such as a patient’s heart rate, blood pressure, respiratory rate, etc.
- Physical Examination: This section depicts the usage of percussion instruments used to detect the presence of abnormal fluids, a stethoscope used to evaluate the valvular function and heart rhythm, and other such physical examination tools.
- ROS or Review of Systems: This section relates to the patient’s organ system and organizes a list of questions meant to identify irregularities and diseases.
- HPI (history of present illness)
- CC or Chief Complaints: Lastly, this section will list information about the origins of the patient’s problem / what invoked the patient to seek medical treatment.
Who can access a medical chart?
HIPPA Privacy Rule gives patients the right to their health information and sets limits on who is capable of receiving and seeing their information. Thus, only patients, their elected representatives, or a permissible healthcare professional have access to one’s records upon request. This means that everything stored within an EMR / EHR system cannot be accessed or shared without explicit permission.
Standards for accessing information
According to the Privacy Rule, a HIPAA-covered entity has to give individuals access to their protected information. Yet, the information should be about them in one or more designated record sets that the covered entity maintains. Consequently, an individual can get a copy of or inspect their protected health information (PHI) if they wish. They can direct the covered entity to send a copy to a certain person or entity of their choosing. Moreover, an individual can access this PHI during the period of coverage by the HIPPA-compliant entity.
In regards to the distribution and sharing of access to a patient’s information before EMRs/EHRs, it was never a streamlined process. A physician’s office or a surgical center would use fax, email, and even tangible mail to share patient information. Nowadays, the standards have drastically changed, as the use of patient portals and connected EHRs allow physicians and patients alike to access information quickly and efficiently.
Ambula: The Future Of ASC Medical Charts
Ambula EMR system provides similar solutions with a lawyer portal for personal injury cases and a billing portal for medical billers who want access to patient information to submit claims accurately. Mainly, this digital system is becoming the new standard for safely granting access to patient information. As long as HIPAA regulations are followed and the channel of distribution used to share patient information is ensured to be secure, then the ease at which such information is shared will remain unmatched. In conclusion, medical charts are a very delicate and significant area within the healthcare field. One tiny mistake can result in irreversible damage. Therefore, it is important to secure the most effective and revolutionary approach to electronic medical charting available, one of which is the Ambula ASC-focused EMR.
To find out more about medical charts and how Ambula can improve your EMR experience, feel free call the Ambula Healthcare team at: (818) 308-4108. And now, are free EMRs effective?