Medical charts provide healthcare providers a glimpse into a patient’s medical history and provide vital details to help clinicians make sound care decisions.
A medical chart is a thorough record of a patient’s medical history and clinical data. Information such as demographics, vital signs, diagnoses, surgeries, medications, treatment plans, allergies, laboratory results, radiological studies, immunization records is included.
Several healthcare professionals can add information to medical charts, including physicians, nurses, radiological technicians, laboratory technicians, and other members of a healthcare team. Complete medical charts help ensure patients receive the best care possible.
What Information is Included in the Medical Chart?
Medical charts contain medically relevant events that have happened to a person. A good medical chart will paint a clear picture of the patient. It also provides vital information to allow healthcare practitioners to make sound decisions based on the information contained in the record.
Medical charts include:
- Demographics – name, contact information, age, etc.
- Developmental History – growth charts, motor development, cognitive development, social/emotional development, language development, etc.
- Immunization Records – vaccinations and dates
- Medical allergies
- Surgical history – operation dates, reports
- Obstetric history – the number of pregnancies, complications, pregnancy outcomes
- Family History – immediate family health status, the cause of death, common family diseases
- Social History – past and current occupations, community support, etc.
- Habits – alcohol consumption, exercise, diet, smoking, sexual history
At each medical encounter, the following information will be added to the patient’s chart:
- Chief complaint
- History of present illness
- Physical exam (vital signs, organ system overview, etc.)
- Assessment and plan (diagnosis and treatment)
- Orders (lab, radiological, etc.)
- Progress notes
- Test results (lab testing, imaging results, etc.)
Who Has Access to a Medical Chart?
Individual medical charts must be treated with extreme care. Only the patient and the healthcare team members involved in their care are allowed to view or add to a medical chart.
Medical charts belong to the patient. He or she has the right to make sure the chart is accurate and can grant another party access to the chart. If a patient finds inaccuracies in their chart, they can petition their providers to make amendments to ensure accurate medical records.
What is an EHR?
An electronic health record, or EHR, is best described as a digital version of a patient’s medical chart. EHRs are real-time records that make health information available instantly.
EHRs can share information quickly and securely between a patient’s entire care team. EHRs are built to share medical information between physicians and other healthcare providers such as laboratories, specialists, medical imaging facilities, emergency facilities, schools, and pharmacies to provide a clear picture of a patient’s history to make smart care decisions.
EHRs also provide support for other care-related activities such as easy access to evidence-based decision support, instant information on medications, quality management, and more.
How Do EHRs Help?
Having access to electronic medical records gives physicians instant access to vital health information to make the best possible care decisions.
EHRs are useful in many ways such as:
- Reducing medical errors in charts due to poor penmanship
- Improving accuracy and clarity of coordination of care
- Making health information easily accessible, reducing test duplications and treatment delays
- Allowing patients to see their records and make needed changes to ensure accurate records
- Guarantees medical charts are never lost and easily accessible
Whether paper or electronic, medical charts follow patients where they go, and accurate records are key to providing excellent medical care.