A medical report is an encompassing and comprehensive report that includes the medical history and details about a person when they have a consultation with a health service provider or when they are admitted to a hospital. They are useful for a variety of reasons for all the parties involved such as the health care providers, insurance companies, and even the patients. In fact, high-quality medical records are a pivotal part of effective healthcare.
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A medical report is also a vital piece of evidence that proves what treatment has been given to the patient, as well as specific conditions that affect a patient. The terms medical report, health record, and patient are used somewhat interchangeably to convey the same meaning. Medical reporting should include the following, however, this is not a limited list:
- Personal information such as age, sex, and weight
- An overview of medical history
- Documentation of diagnosis
- Documentation of any medications
- Findings of physical and mental examinations
- History of Allergies
- History of hospitalizations
- History of treatments and response to treatments
- Laboratory test results and medical images like X-rays
- Statements confirming your limitations and abilities
Several of these records are dated and confirmed by doctors and nurses. They also contain daily findings of vital signs if the person was hospitalized. These in daily patient records, vital signs such as pulse, breathing rate, temperature, and blood pressure are noted. These are important to monitor and measure because they can be used to assess levels of physical functioning and they reflect essential body functions.
Who makes medical reports?
Patient reporting enables health care providers to have insights into the patient’s medical history to give the necessary informed care. The medical report functions as the central framework for planning patient care as well as communication among patients and health care providers or other professionals contributing to the patient’s care.
These healthcare professionals are those who make patients documentation. Those in this field include physicians, doctors of Osteopathic Medicine, surgeons, nurses, dentists, midwives, psychologists, psychiatrists, or pharmacists, and those others who perform services in allied health professions.
Ideally, medical reporting is completed by a doctor or medical professional who is certainly familiar with the patient’s condition or a medical professional who has treated the patient for a significant period of time.
Hospital nursing units are responsible for adding hard copy data such as information from chemistry and hematology testing, microbiology procedures, cytology slides, and printouts from automated analyzers, X-ray films and reports, ECG traces, and blood bank testing such as antibody information and patient blood types to the patient report. They have immediate access to this data once it is verified.
Therefore each report contains the newest test result activity, and only re-displays previous information when a test is part of a profile that was partially resulted in the first report. Every entry also has a collection date and time as well as the received date and time ordered tests.
Medical reports can include admission notes, on-service notes, progress records, preoperative notes, operative notes, postoperative notes, procedure notes, delivery records, postpartum records, and discharge notes. These are typically for inpatient care and are merged to form a holistic record of the patient’s health history as a personal health record. These can sometimes be accessed by the patient and shared across health care systems and providers.
Currently, many paper reports have transitioned to electronic reporting, which is earlier to distribute to other professionals contributing to patient health care. The improved portability is ideal but it presents its own challenges such as difficulty to keep patients records safe as well as the accessibility of patient reports.
Why is medical reporting important?
An appropriate well-organized medical report is essential for good medical practice and continuity of care. Therefore, a patient recording is recognized as an important component of professional standards.
Since medical records cover an array of documents that are generated as a result of patient care, they have invaluable benefits such as:
- validating and supporting patient claims for Social Security Disability benefits
- supporting reimbursement for health services provided
- identifying people who have had specific treatments
- discovering treatments that may have caused some adverse events
- providing evidence of injury and treatment for workers’ compensation
- studying disease trends to identify potential environmental or genetic causes
- tracking changes in your physical findings such as the progress of tumors or edema
Who has access to medical reports?
High-quality medical reporting is important for building a partnership of trust between the patient and medical health professionals. This principle of trust should be instilled into the accessibility of medical reports. However, healthcare providers should be discrete but depending on the country, they have permission to release medical records without authorization.
Others who might have access to medical records include insurance companies for bills or claims management and purposes of processing health insurance coverage. Also, professional societies and research organizations who are reviewing health care providers or doing medical research might have access to patient reports. Employers can also request to access patient records when evaluating workers’ compensation claims.
In the United States in 1996, the Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress. It specifies who has access to your medical records and personal health information.
Under HIPAA privacy rights, US citizens can have access to their personal medical records. However, the law sets limitations on the use and release of medical records, as well as an established series of privacy standards for healthcare providers.
In the UK, the Access to Medical Reports Act 1988 provided patients the right to see any medical report relating to them and the Access to Health Records Act 1990 gave them the right to inspect their own records.
Recently, the UK Parliament passed an act placing the role of the National Data Guardian (NDG) for Health and Social Care on a statutory footing. Therefore allowing the NDG to issue statutory guidance about the processing of health and adult social care data including third-party groups such as Google and Amazon.
Australia has a similar approach to the UK. In Australia, contacting the health service provider for your health information is possible and they can grant you access. You can also authorize, a legal guardian or authorized representative While in Europe, European citizens have to access their electronic medical records across the in full compliance with the General Data Protection Regulation.