What are the various functions of medical records?
Medical records have functional implications for health care professionals, patients, insurance companies, the government, attorneys, and researchers.
Any information relevant to our physical and/or mental health care should be recorded because neither the people who treat us nor we can possibly remember everything. Without record-keeping, those who treat us would be re-inventing the wheel every time, having to get basic demographic information, a medical history, blood type, any allergies, and so on. All of this information is vital to treat us properly. What went before is often an explanation for a presenting symptom, which means that diagnosis can be dependent on medical records, for example, an old injury might result in arthritis in later years. In terms of treatment, medical records serve the function of preventing contradictory treatments and eliminating duplicate treatment. In today's world, with all of its medical specialties and ancillary services, for example, physical therapy or occupational therapy, no matter who is treating the patient, there is a "big picture" that allows for more tailored and better treatment.
All of this assures better medical care for us as patients, and it also allows us to avoid countless recitations in countless health care settings. A doctor will not order a treatment that the record shows was unsuccessful or prescribe a drug that the patient is allergic to. Today, because of electronic medical record keeping, a patient may travel and be able to count on information being available no matter where he or she goes.
Insurance companies rely on medical records to pay claims, of course, and this makes proper record-keeping essential. No insurance company will pay for treatment that is not properly documented.
The government also relies on medical records to pay claims, through Medicare and Medicaid programs. Additionally, the government, in its capacity for being responsible for public health, uses medical records to spot various trends, for example, diabetes or heart disease, and in particular, to provide epidemiological trends of communicable diseases such as influenza. Medical records allow the government to have a clearer understanding of our health generally, and provide the basis for various kinds of government aid or intervention.
Researchers rely on medical records to learn more about us, usually records that have been redacted of any identifying information. This is the kind of research that can tell a hospital what its infection rate in surgery is, whether one prosthetic device is more effective than another, or which kind of diagnostic tool is more efficacious in spotting a disease or condition. Without medical records, we would not be able to make medical advances very well.
So, all in all, medical records are a necessity for all of the stakeholders in health care. It is difficult to conceive of a health care situation in which we could do without them, although there are no doubt places in the world where that does happen.