Medical Records

Medical records are the written reports, results of laboratory tests, photographs and video tapes relating to the patient’s physical conditions, symptoms, manifestations, and treatment. These are usually paper-based records that are kept in Medical Records Sections of hospitals and other healthcare organizations. Due to technological advancements, health or medical records are now being transferred to computer-based system. These are now called Electronic Health Records (EHR).

The transfer of paper-based records to computer-based system should have to first undergo a process wherein the paper-based records are scanned into an electronic management system, usually the computer, with the application principles for paper-based records. The computer unit to be used must be of standard quality and efficient equipment. The computer program used to generate the record must be reliable and functioning properly, and records should be stored in a format that only a computer can process. With regards to the record itself, the records should always show factual information and written in factual statements.

All record entries must be legible and made in black ink to facilitate clear photocopying. Clinical data from other facilities should be well-defined as to whether the data is in its entirety or abstracted and should be evaluated the clinician. The name of the patient and medical record number must be stated on every page of the health record. Timeliness and chronology of entries must be properly followed showing the complete and continuous chronology of the patients’ healthcare, complete with date and time. All EHR must be permanent in order to prevent deterioration and loss of integrity during system conversion.

Records must also be properly authenticated and signed by authorized personnel. New re-engineering process must be implemented to ensure well-designed workflow for the EHR transition. For security measures, aside from assigning trained personnel to safeguard confidential electronic data, password must be provided in order to control access to data system. Environmental consideration such as humidity, temperature, and cleanliness must be maintained to prevent potential loss or alteration of records. On the aspect of accessibility, records must be accessible for the length of the retention period no matter what type of technology is used.

During transition period, records stored in microfilm or microfiche must be retained in the hardware component of the computer system to allow ready access or reproduction of records. Considerations must also include “back-up” compatibility to previous system from the upgraded system as technology changes. In conclusion, this student finds that no matter what technique is used in storing medical records, the fact still remains that medical records must be stored and maintained in a manner that follows the regulation, accreditation standards, professional standard of practice, and legal standards.


Keeping and destroying records. (2008). OA/OMA. Retrieved June 22, 2009, from http://www1. od. nih. gov/oma/manualchapters/management/1743/. Maintaining a legally sound health record-paper and electronic. (2008). AHIMA. Retrieved June 22, 2009, from http://library. ahima. org/xpedio/groups/public/documents/ahima/bok1_028509. hcsp? dDocName=bok1_028509.

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