Details About A Personal Medical Record

By Maryellen Lamb


The various documents that include details about the medical history of an individual are known as a personal medical record. These may be put together by health professionals or individuals themselves. Whatever the case, the info is considered private and personal. Often the records include a history of health problems, medications, treatments and more. This data, whether on paper or in electronic databases, can be request by the individual. There are health laws in place that require these records to be made available within 30 days of requests.

These files are designed to be all-inclusive and available to health professionals so that they can better serve their patients. Knowing this history of patient can give doctors a better idea of how to treat or prevent other issues. As these records also include information about medication and allergies, it can ensure that non-effective or harmful treatments are not used. This type of information is especially important in emergency situations where individuals may be unable to provide professionals with vital information.

Records include more than just information about past injuries, illnesses, medical treatments, allergies and family health history. In fact, most of the files have the names and contact information of all of the doctors who the patient has seen, lab results and details about the insurance an individual has. All of this is crucial when it comes to providing proper care.

All of the data included in these files is considered personal and sensitive. Because of this, a high level of privacy is expected with handling records. There are both ethical and legal issues related to accessing and maintaining these files. The info included in such records, in the majority of jurisdictions, is considered the property of a patient and no one else. However, laws regarding ownership and keeping of the files differ by country.

Medical history is referred to as a longitudinal record of what has occurred to a patient, in terms of health, since they were born. It includes major illnesses, growth landmarks, minor illnesses, diseases and more. This allows professionals to get a better understanding of the past of a patient so that they can help them in the present time or to prevent future problems. Subsets of the term: development history, growth chart, habits, social history, allergies, surgical history, medications, immunization history, family history and obstetric history.

In these records there are medical encounters that include discrete summaries of health history as documented by nurse practitioners, physicians or physician assistants. Each of these encounters typically includes a few elements. Some examples of aspects found in encounters: chief complaint, history of the current illness, physical exams, and assessment and plan.

People might choose to have their own records, though they may not be as detailed as those made by the professionals. In either case, having this important info available is ideal, especially for patients who suffer with many health problems. A number of computer programs are available that can aid in filing and organizing such info, but privacy should be a concern and priority.

A personal medical record is the private file of an individual that outlines all information related to their health care. This information should be kept private. It is accessible to professionals so that they may better care for their patients.




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