Details About A Personal Medical Record

By Maryellen Lamb


Personal medical record is the documents that outline the health history of a patient. An individual or his or her doctors are the individuals who put these files together. The information included is regarded as private and personal. Of then records include a full history of health problems, medications, treatments and more. The information, whether it is in paper or electronic form, may be requested by the patient. Health laws mandate that these records be given to the approved party within one month of a request date.

The files are meant to include all details. They are made available to health professionals so that these individuals can serve patients to their best ability. This knowledge of a patient can give professionals an idea on how to prevent or treat issues. These records might also have information about allergies and medication, which can keep harmful or non-effective treatments from being applied. The info is particularly important in cases of emergency when an individual may not be able to provide professionals with the facts they need.

Records include more than just information about past injuries, illnesses, medical treatments, allergies and family health history. In fact, most of the files have the names and contact information of all of the doctors who the patient has seen, lab results and details about the insurance an individual has. All of this is crucial when it comes to providing proper care.

The data in these records is personal and sensitive. This is why they should be kept private. Ethical and legal issues surround the maintenance and access of such files. In the most jurisdictions, this is considered property of a patient and no other individual. Still, each country has different rules regarding the keeping and ownership of such records.

Medical history is considered a longitudinal account of what has happened with a patient since their date of birth. It includes diseases, minor and major illnesses, growth landmarks and more. This gives professionals a summary of what has happened to a patient in the past, which may help them treat present or future conditions. There are subsets with this term: obstetric history, family history, habits, surgical history, social history, allergies and medications, development history and growth chart and immunization history.

In the records is medical encounters. This is essentially general summaries of health history that have been documented by physicians, physician assistants and nurses. Most encounters include the same basic elements: main complaint, physical examinations, history of illness, assessment of problem and plan for treatment.

Those who want to create their own personal records may find that the files are not as extensive as those kept by the professionals. Still, it is ideal to have this info readily available, especially by those who suffer with many health problems. There are programs that can be used on basic computers that aid in logging this information, but privacy should be a concern and a priority.

The personal medical record of an individual includes files that have all of the info related to health care of the patient. The info should be private. Although it is available to health care professionals to allow them to offer the best possible care.




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