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A lot of energy wasted upon discussing merging would be saved if a tree is used in the see also section. Illustration is given below. Editors are requested to the category page, and flesh out the tree. Suggest moving this tree to the see also section Sanjiv swarup ( talk) 10:21, 6 July 2008 (UTC)
This record is a whole long write. I've tried to do it in several sittings; however, I decided to string out the headers and do some fill in afterward. DrGnu 07:05, 3 Nov 2004 (UTC)
The second sentence in the introductory paragraph states: "Although medical records are held by the physician they are the legal property of the patient." Perhaps this depends upon the state or country. In my state, medical records are the legal property of the physician but the patient is legally entitled to a copy of anything in his or her record. Anyone monitoring this page who would care to comment? Edwardian 05:56, 5 August 2005 (UTC)
In Australia, in general, the medical records held in a doctor's surgery/office are held to belong to the doctor, but the information contained belongs to the patient! In hospitals the medical record is the property of the hospital. Privacy legislation here means that although the record doesn't belong to the patient, the patient's permission must be sought to release the information, to another doctor (for example taking over care) or to an insurance company, to the Roads and Traffic Authority (for drivers licence information). Lbandler 07:41, 20 September 2005 (UTC)
I rewrote this section, partly to tidy english (eg "Prolonged elevated .....Prolonged depressions....") and partly as some inaccuracies.
NB I thank Gene Nygaard for correcting my initial Celsius/Farenheit conversion errors and pointing out that the values are not a fixed value. David Ruben talk 11:13, 24 September 2005 (UTC)
User:Lotsofissues has suggested a merging with the existing Medical records. There are two separate aspects covered by both the current Medical record and Medical records
I think both aspects are sufficienty large that a single article would be too long. However careful redirection is needed between the two pages as 'Medical record' is so very close to 'Medical records'. Either that or rename them a 'Medical record (clinical)' and 'Medical records (administation)' with redirects from the current pages ? For now, much of the current WP:MCOTW article would be better within Medical records and both articles should be edited as this weeks project? David Ruben talk 11:34, 24 September 2005 (UTC)
I agree - I like the idea of a clinical medical record and an administrative medical record division. This is a useful way to think about it. I think that the [medical record] and [medical records] be merged. However I think that there is some confusion about medical record/s/history because doctors tend to use words that are in general use in specific ways.
OK, seems consensus to merge (with info off to physical examination) - I'm happy to do this, and will do so over the next few days - David Ruben talk 00:53, 30 September 2005 (UTC)
Medical records merged into this article; if you wish to see its history of edits then follow this link. Likewise details of the examination moved to the existing physical examination article. - David Ruben talk 16:57, 30 September 2005 (UTC)
The whole article is much better now! -- WS 00:06, 1 October 2005 (UTC)
It reads a lot better and looks a lot better InvictaHOG 04:31, 4 October 2005 (UTC)
I went ahead and made some additions, deletions, and formatting changes to the contents section. It seemed fairly jumbled to me and hopefully I made a dent in organizing it. I won't be offended if you think it's worse! I don't know if there's some easy way to make a box or something with the main headers of the contents section - I feel that the bullets do a little better job letting people know where things belong but think it would be nice to have something to quickly scan showing that demographics, progress notes, etc. all belong directly to contents. In any event, I'm not as qualified to change the administrative issues, though I believe they need quite a bit of work! It's difficult to tell what's the US and what's the UK. We should probably just divide up. Also, the EMR bit is not straight-forward. I might take a stab at it tomorrow...
Is there a duty to review the medical record prior to treating the patient? What is the scope of the physicians or nurses duty? Should this be part of the article? - Bill Smoot
Could there be a section on ethical considerations? Eg, Should patients have the right to request that medical records not be kept? Should patients have the right to ask that medical records be destroyed? Should patients have more say over who gets to see their medical records, for instance saying that *only* their own doctor can see them, not other doctors in the same practice or reception staff? Should patients have the right to anonymous health care? Personally, I hate the fact that doctors keep records about me, if I had a say in it, I'd have them burnt in 2 seconds flat. It also makes alternative health providers (like naturopaths, acupuncturists etc) seem a lot more attractive, because at least with them your anonymity is protected, and no records are kept.
How long are medical records kept in the US? I do not see this mentioned in the article. Danny ( talk) 13:54, 9 January 2008 (UTC)
I think there should be no doubt that these 2 terms - Medical Records and Health Reacords - are, and can be, used interchangeably as synonyms, without major conceptual incorrections. In fact, there is usually no significant loss of meaning by expressing one term over the other.
Ceci étant dit, let us not overemphasize that there should be no confusion between them, either; specially if a specific context requires us to choose between one over the other when meaning could be comprimised if equivalence is not applicable interchangeably. Thus, I proposed one section on that, hoping it will help clarify these discussions.
alo_world —Preceding
unsigned comment added by
Alo world (
talk •
contribs)
08:18, 30 March 2009 (UTC)
I know what MRN is: medical record number, but I swear I've heard other physicians say PF#... but I can't figure out what the acroyn for that might be. Anyone? Is there an article that addresses these abbreviations relating to the medical record? 163.40.12.37 ( talk) 19:35, 8 December 2009 (UTC)
What is the job outline for medical records clerk? —Preceding unsigned comment added by 198.99.244.32 ( talk) 20:50, 18 February 2010 (UTC)
I've started a discussion at the electronic medical record page; please participate in the discussion there as the links being added here seem to be related and we can keep the discussion together. Thanks! Flowanda | Talk 20:11, 18 April 2010 (UTC)
I've edited this article to fix an inconsistency yesterday ( this edit)
There had been stated 'Hence the patient's record belongs to the patient.', in the article's 'Informational self-determination' section.
Actually, reading further on, it came out that:
and so on.
So it's not true that 'the patient's record belongs to the patient', and there was an inconsistency in the article.
I fixed it, making an edit, changing the sentence to 'Hence the should patient's record belongs to the patient, but it seldom happends.' (should = it should be, but not always is. It seldom = becouse it does not happend in any of the countries that were dealt in the article).
But that edit was immediately reverted by another user.
(Sorry for my not so good english, I'm not English native speaker) -- 79.20.147.77 ( talk) 20:37, 8 July 2010 (UTC)
Doctor's make their patient's medical records or their own medical record technician it depends some doctor's know how to make medical records some don;t so the point of a'medical record technician is to help the doctors with making their patient's medical records medicals are private and inportant they must be placed in a folder or a medical record case or a filing cabinet. to see medical records examples or forms or real medical records ask your doctor or go online.— Preceding unsigned comment added by 98.110.215.132 ( talk • contribs) 14:47, 26 February 2011
There is no section about Norway. This link [6] tells about the Minister of Health's suggestion for a law proposal: that doctors working at any particular office should have access to all the medical records that the other doctors there have written (while working there).-- 85.164.146.94 ( talk) 13:34, 18 December 2011 (UTC)
The history of the use of medical records is beyond the scope of this article. However a brief summary of the origins of the medical record in the West may be found at the following website: "History of medical record-keeping", Casebooks Project ( http://www.magicandmedicine.hps.cam.ac.uk/on-astrological-medicine/further-reading/history-of-medical-record-keeping/) (Accessed 2012-09-25). I removed this. A better solution would be to actually write a history section.-- Atlantima ~✿~ ( talk) 21:55, 26 April 2013 (UTC)
The "Media Applied" section has a claim that implies that the Mayo Clinic invented a single-dosier medical record. This really needs a citation - I have placed a tag there, in the hopes that someone will find a citation.(I see the Mayo Clinic page itself says that the Clinic "Created an integrated medical record" but gives no details, and I don't think that the Clinic's own advert page can be used as a reliable citation.). In addition, there does not appear to be a logical reason why this claim is in the "Media Applied" section. Kmasters0 ( talk) 07:35, 21 September 2016 (UTC)
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Currently there is a parochial template(I don't know what else it's called), informing readers that the Privacy section is primarily about Privacy in the United States. Might it be appropriate to begin that section (until or if the section is improved to cover Privacy concerns in other places), by stating, "In the United States, ..."? Would anyone have any objection if I added that statement to the beginning of the section? And the next sentence says, "Not only is it bound by the Code of Ethics...", but I wonder exactly what does 'it' refer to? Is it referring to HIPAA in particular, or Privacy in general, or what? If it's Privacy in general, couldn't the word 'privacy'(or the phrase 'the privacy of patients') replace 'it'? And then there is a sentence which says, "The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel.", but shouldn't the word 'implies' be 'applies', to make some sense (with the later change of 'in' to 'to'), so that the sentence would read, "The maintenance of the confidentiality and privacy of patients applies first of all to the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel." (minus the bolding of the words)? I'm not comfortable just making those changes without some discussion, even though I think my changes make the sentence make better sense. UnderEducatedGeezer ( talk) 05:58, 19 July 2020 (UTC)
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.
Someone should change 'jurisdiction' to 'specialty' or 'area of expertise' or better yet 'discipline'. 'Jurisdiction' is a special word that means where the 'law can be spoken' and has nothing to do with whether a doctor under the law is seen as a legal provider of care. 71.225.252.204 ( talk) 18:39, 26 July 2021 (UTC)
![]() | This article is rated B-class on Wikipedia's
content assessment scale. It is of interest to the following WikiProjects: | |||||||||||||
|
A lot of energy wasted upon discussing merging would be saved if a tree is used in the see also section. Illustration is given below. Editors are requested to the category page, and flesh out the tree. Suggest moving this tree to the see also section Sanjiv swarup ( talk) 10:21, 6 July 2008 (UTC)
This record is a whole long write. I've tried to do it in several sittings; however, I decided to string out the headers and do some fill in afterward. DrGnu 07:05, 3 Nov 2004 (UTC)
The second sentence in the introductory paragraph states: "Although medical records are held by the physician they are the legal property of the patient." Perhaps this depends upon the state or country. In my state, medical records are the legal property of the physician but the patient is legally entitled to a copy of anything in his or her record. Anyone monitoring this page who would care to comment? Edwardian 05:56, 5 August 2005 (UTC)
In Australia, in general, the medical records held in a doctor's surgery/office are held to belong to the doctor, but the information contained belongs to the patient! In hospitals the medical record is the property of the hospital. Privacy legislation here means that although the record doesn't belong to the patient, the patient's permission must be sought to release the information, to another doctor (for example taking over care) or to an insurance company, to the Roads and Traffic Authority (for drivers licence information). Lbandler 07:41, 20 September 2005 (UTC)
I rewrote this section, partly to tidy english (eg "Prolonged elevated .....Prolonged depressions....") and partly as some inaccuracies.
NB I thank Gene Nygaard for correcting my initial Celsius/Farenheit conversion errors and pointing out that the values are not a fixed value. David Ruben talk 11:13, 24 September 2005 (UTC)
User:Lotsofissues has suggested a merging with the existing Medical records. There are two separate aspects covered by both the current Medical record and Medical records
I think both aspects are sufficienty large that a single article would be too long. However careful redirection is needed between the two pages as 'Medical record' is so very close to 'Medical records'. Either that or rename them a 'Medical record (clinical)' and 'Medical records (administation)' with redirects from the current pages ? For now, much of the current WP:MCOTW article would be better within Medical records and both articles should be edited as this weeks project? David Ruben talk 11:34, 24 September 2005 (UTC)
I agree - I like the idea of a clinical medical record and an administrative medical record division. This is a useful way to think about it. I think that the [medical record] and [medical records] be merged. However I think that there is some confusion about medical record/s/history because doctors tend to use words that are in general use in specific ways.
OK, seems consensus to merge (with info off to physical examination) - I'm happy to do this, and will do so over the next few days - David Ruben talk 00:53, 30 September 2005 (UTC)
Medical records merged into this article; if you wish to see its history of edits then follow this link. Likewise details of the examination moved to the existing physical examination article. - David Ruben talk 16:57, 30 September 2005 (UTC)
The whole article is much better now! -- WS 00:06, 1 October 2005 (UTC)
It reads a lot better and looks a lot better InvictaHOG 04:31, 4 October 2005 (UTC)
I went ahead and made some additions, deletions, and formatting changes to the contents section. It seemed fairly jumbled to me and hopefully I made a dent in organizing it. I won't be offended if you think it's worse! I don't know if there's some easy way to make a box or something with the main headers of the contents section - I feel that the bullets do a little better job letting people know where things belong but think it would be nice to have something to quickly scan showing that demographics, progress notes, etc. all belong directly to contents. In any event, I'm not as qualified to change the administrative issues, though I believe they need quite a bit of work! It's difficult to tell what's the US and what's the UK. We should probably just divide up. Also, the EMR bit is not straight-forward. I might take a stab at it tomorrow...
Is there a duty to review the medical record prior to treating the patient? What is the scope of the physicians or nurses duty? Should this be part of the article? - Bill Smoot
Could there be a section on ethical considerations? Eg, Should patients have the right to request that medical records not be kept? Should patients have the right to ask that medical records be destroyed? Should patients have more say over who gets to see their medical records, for instance saying that *only* their own doctor can see them, not other doctors in the same practice or reception staff? Should patients have the right to anonymous health care? Personally, I hate the fact that doctors keep records about me, if I had a say in it, I'd have them burnt in 2 seconds flat. It also makes alternative health providers (like naturopaths, acupuncturists etc) seem a lot more attractive, because at least with them your anonymity is protected, and no records are kept.
How long are medical records kept in the US? I do not see this mentioned in the article. Danny ( talk) 13:54, 9 January 2008 (UTC)
I think there should be no doubt that these 2 terms - Medical Records and Health Reacords - are, and can be, used interchangeably as synonyms, without major conceptual incorrections. In fact, there is usually no significant loss of meaning by expressing one term over the other.
Ceci étant dit, let us not overemphasize that there should be no confusion between them, either; specially if a specific context requires us to choose between one over the other when meaning could be comprimised if equivalence is not applicable interchangeably. Thus, I proposed one section on that, hoping it will help clarify these discussions.
alo_world —Preceding
unsigned comment added by
Alo world (
talk •
contribs)
08:18, 30 March 2009 (UTC)
I know what MRN is: medical record number, but I swear I've heard other physicians say PF#... but I can't figure out what the acroyn for that might be. Anyone? Is there an article that addresses these abbreviations relating to the medical record? 163.40.12.37 ( talk) 19:35, 8 December 2009 (UTC)
What is the job outline for medical records clerk? —Preceding unsigned comment added by 198.99.244.32 ( talk) 20:50, 18 February 2010 (UTC)
I've started a discussion at the electronic medical record page; please participate in the discussion there as the links being added here seem to be related and we can keep the discussion together. Thanks! Flowanda | Talk 20:11, 18 April 2010 (UTC)
I've edited this article to fix an inconsistency yesterday ( this edit)
There had been stated 'Hence the patient's record belongs to the patient.', in the article's 'Informational self-determination' section.
Actually, reading further on, it came out that:
and so on.
So it's not true that 'the patient's record belongs to the patient', and there was an inconsistency in the article.
I fixed it, making an edit, changing the sentence to 'Hence the should patient's record belongs to the patient, but it seldom happends.' (should = it should be, but not always is. It seldom = becouse it does not happend in any of the countries that were dealt in the article).
But that edit was immediately reverted by another user.
(Sorry for my not so good english, I'm not English native speaker) -- 79.20.147.77 ( talk) 20:37, 8 July 2010 (UTC)
Doctor's make their patient's medical records or their own medical record technician it depends some doctor's know how to make medical records some don;t so the point of a'medical record technician is to help the doctors with making their patient's medical records medicals are private and inportant they must be placed in a folder or a medical record case or a filing cabinet. to see medical records examples or forms or real medical records ask your doctor or go online.— Preceding unsigned comment added by 98.110.215.132 ( talk • contribs) 14:47, 26 February 2011
There is no section about Norway. This link [6] tells about the Minister of Health's suggestion for a law proposal: that doctors working at any particular office should have access to all the medical records that the other doctors there have written (while working there).-- 85.164.146.94 ( talk) 13:34, 18 December 2011 (UTC)
The history of the use of medical records is beyond the scope of this article. However a brief summary of the origins of the medical record in the West may be found at the following website: "History of medical record-keeping", Casebooks Project ( http://www.magicandmedicine.hps.cam.ac.uk/on-astrological-medicine/further-reading/history-of-medical-record-keeping/) (Accessed 2012-09-25). I removed this. A better solution would be to actually write a history section.-- Atlantima ~✿~ ( talk) 21:55, 26 April 2013 (UTC)
The "Media Applied" section has a claim that implies that the Mayo Clinic invented a single-dosier medical record. This really needs a citation - I have placed a tag there, in the hopes that someone will find a citation.(I see the Mayo Clinic page itself says that the Clinic "Created an integrated medical record" but gives no details, and I don't think that the Clinic's own advert page can be used as a reliable citation.). In addition, there does not appear to be a logical reason why this claim is in the "Media Applied" section. Kmasters0 ( talk) 07:35, 21 September 2016 (UTC)
Hello fellow Wikipedians,
I have just modified one external link on Medical record. Please take a moment to review my edit. If you have any questions, or need the bot to ignore the links, or the page altogether, please visit this simple FaQ for additional information. I made the following changes:
When you have finished reviewing my changes, you may follow the instructions on the template below to fix any issues with the URLs.
This message was posted before February 2018.
After February 2018, "External links modified" talk page sections are no longer generated or monitored by InternetArchiveBot. No special action is required regarding these talk page notices, other than
regular verification using the archive tool instructions below. Editors
have permission to delete these "External links modified" talk page sections if they want to de-clutter talk pages, but see the
RfC before doing mass systematic removals. This message is updated dynamically through the template {{
source check}}
(last update: 5 June 2024).
Cheers.— InternetArchiveBot ( Report bug) 08:51, 24 January 2018 (UTC)
Currently there is a parochial template(I don't know what else it's called), informing readers that the Privacy section is primarily about Privacy in the United States. Might it be appropriate to begin that section (until or if the section is improved to cover Privacy concerns in other places), by stating, "In the United States, ..."? Would anyone have any objection if I added that statement to the beginning of the section? And the next sentence says, "Not only is it bound by the Code of Ethics...", but I wonder exactly what does 'it' refer to? Is it referring to HIPAA in particular, or Privacy in general, or what? If it's Privacy in general, couldn't the word 'privacy'(or the phrase 'the privacy of patients') replace 'it'? And then there is a sentence which says, "The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel.", but shouldn't the word 'implies' be 'applies', to make some sense (with the later change of 'in' to 'to'), so that the sentence would read, "The maintenance of the confidentiality and privacy of patients applies first of all to the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel." (minus the bolding of the words)? I'm not comfortable just making those changes without some discussion, even though I think my changes make the sentence make better sense. UnderEducatedGeezer ( talk) 05:58, 19 July 2020 (UTC)
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.
Someone should change 'jurisdiction' to 'specialty' or 'area of expertise' or better yet 'discipline'. 'Jurisdiction' is a special word that means where the 'law can be spoken' and has nothing to do with whether a doctor under the law is seen as a legal provider of care. 71.225.252.204 ( talk) 18:39, 26 July 2021 (UTC)