Talk:Medical record

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This article was previously a Medicine Collaboration of the Week.


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)

Contents

[edit] Introductory paragraph

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)

I did a brief search and found multiple references from multiple States stating that the medical record belongs to the physician, but none stating it belongs to the patient [1][2][3][4][5]. I think that is sufficient to warrant the change right now, although maybe those outside the U.S. could comment. Edwardian 05:35, 25 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)

[edit] Temperature

I rewrote this section, partly to tidy english (eg "Prolonged elevated .....Prolonged depressions....") and partly as some inaccuracies.

  • The need to record temperature in the medical record is what is required in this article, not a full discussion on all different methods of measurement and their relative pros & cons. So I wanted to cut down on the fuller discussion (the article will get longer as other sections are completed).
  • Likewise core temperature spent too much discussing other methods and so I simplified that too and place the additional info in a new article of Temperature examination
  • Having the current blind links to oral temperature & rectal temperature is not, I think, appropriate as neither ever will need be a full article and both can be encompassed in a single page (hence Temperature examination)
  • Thermosensative material skin measurement is not primarily used in operative measurements (but thermocouple sensing is), rather they are sold in the tens of thousands as a simple children's thermometer
  • Thermocouples need direct contact with what the are to measure the temperature of and are not used by Ear thermometers which do not touch the ear drum. Ear thermometers instead use a device to measure infrared heat emmission. Thermocouples are though indeed found in electronic thermometers, but of the types used for oral, armpit or rectal recording. Thermocouples therefore have replaced glass mercury thermometers (now banned from use in Europe due to toxicity if the thermometer breaks open).

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 Rubentalk 11:13, 24 September 2005 (UTC)

  • All that needs be said about temperature on a page about medical records is to mention that there are four vital signs that are routinely recorded (temperature, respiratory rate, pulse, blood pressure), that temperature is one of them, and that "The patient's temperature is recorded at various times during the day, so it can be examined for patterns which suggest fever." This is not the place to discuss methods. - Nunh-huh 11:23, 24 September 2005 (UTC)
    • I tend agree, but likewise for the whole paragraphs on blood pressure etc. Whilst each is well written and provides good overviews to the fuller topics (nice multiple links within WP), such should be under physical examination - I'll move them there, unless anyone objects in the next day.David Rubentalk 11:37, 24 September 2005 (UTC)

[edit] re merge suggestion with Medical records

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

  1. Clinical: the contents of an individual patient record, ie that it consists of has past history, current problems, correspondence and that each clinical encounter results in details of history, examination, investigations, diagnosis & treatments. It also contains social & family history etc etc.
  2. Administrative: the issue of medical records and accesibility to ones own notes, disclosure to others (ie confidentiality, legal requirements). Also issues of being comprehemnsive & contemparous and kept notes for many years to allow problems (education, audit, verification, disputes etc) to be managed.

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 Rubentalk 11:34, 24 September 2005 (UTC)

  • Thanks for completing the tagging. Though, if you wish to create a separate article for the administrative structure behind medical records, I think you should create a more specific title than "medical records". -lots of issues | leave me a message 12:06, 24 September 2005 (UTC)
  • I agree that the articles should be merged. I like the idea of an eventual "clinical" and "administrative" division of the article. Edwardian 22:06, 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.

Yes, I would say merge them and move all the physical examination stuff to the physical examination article. --WS 09:20, 28 September 2005 (UTC)
I agree with that, too. This article is getting much too detailed in areas it doesn't need to be. Edwardian 05:06, 29 September 2005 (UTC)

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 Rubentalk 00:53, 30 September 2005 (UTC)

[edit] Merge from Medical records

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 Rubentalk 16:57, 30 September 2005 (UTC)

Excellent work! Edwardian 19:28, 30 September 2005 (UTC)

The whole article is much better now! --WS 00:06, 1 October 2005 (UTC)

In fact, I think it is now good enough to justify removing the cleanup tag, which I did. --WS 00:07, 1 October 2005 (UTC)

It reads a lot better and looks a lot better InvictaHOG 04:31, 4 October 2005 (UTC)

[edit] Updated the Contents section

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...

  • The administrative portion is still quite messy. I've pretty much finished what I hoped to accomplish on the clinical side. I'm trying to research the various questions on the administrative side, but it's slow going. I think the whole section may benefit from a re-write and new structure. InvictaHOG 02:31, 5 October 2005 (UTC)
  • Major overhaul of the administrative portion. I still have a ways to go, though. Will continue to work on Security, discussion of electronic record systems, etc. #InvictaHOG 03:29, 6 October 2005 (UTC)

[edit] Duty To Review Medical Record

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

  • Thought this had been covered by the 'Purpose' section, but perhaps need to more explicitly state the legal implications of this ? There is a duty for anyone to "put themselves in a suitable position" to offer appropriate treatment. However need to think carefully on wording - a doctor in an Emergency room has a duty to obtain info from the patient if concious, else attending 3rd parties if present, consider if need or time to contact the patient's usual physician (if known). But still possible will need to treat without any background information... - David Rubentalk 19:06, 5 October 2005 (UTC)
I am not a doctor but I am familiar with a case where a doctor did not review the record prior to rendering treatment and this may have led to the death of a patient from pulmonary emboli. I stumbled on your article and just threw this out as a question because it was a question that I had and so I thought others might have it as well. Bill Smoot 01:31, 6 October 2005 (UTC)
I don't know the answer to your question - how much of the medical record is the physician responsible for is a good question. Many medical records are veritable tomes - no one could be expected to have memorized them for each patient. That said, I'm sure that the legal system does! I'll put an e-mail out to our legal department tomorrow and will update the article with anything I find. InvictaHOG 03:32, 6 October 2005 (UTC)
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