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Introduction Medical records are the documents that describe the history, clinical findings, tests results, medications, and any other medical information about a patient. A precise and correct copy of medical records helps treat a patient. Therefore, it is important for the doctors to always minutely study and go through a patient's medical history before starting the treatment. It is beneficial for both the medical practitioner as well as the patient. By maintaining the records properly, the doctors can prove the efficiency of their treatment. Medical records are reliable for inpatient care and treatment, being the source of true information. Components of Medical Records Up-to-date medical records always contain details like contact information, medical history, and tests results. The contact information includes name, address, phone number, and emergency contact. It also consists of the lifestyle habits of the patient - their dietary habits, history of smoking, alcohol, and drug abuse. The demographic information includes gender, birth date, country and ethnicity, marital status, and state of employment. The documents are: Blood type. Family medical history. Past and current medications. Allergies. Details of a family doctor. Insurance schemes among the medical information and history. Reasons for Maintaining Medical Records There are various reasons why medical records are of great significance in medicine and patient care. Monitoring of the patient: The first and foremost objective of maintaining these records is the proper monitoring of the patient. Medical Research: The information of a particular patient can help in the research of medical matters of other patients with a similar diagnosis. In the case of unique and unusual diseases, the information helps further research. Insurance: The documents provide all the necessary details about the patient's insurance schemes and policies, which further help their treatment plans. This is also helpful in the matter of accidental and criminal cases. Medical records improve the overall healthcare and safety of the patients. The effectiveness and efficiency of the treatment can be better tracked by keeping proper and accurate medical records. Due to the increasing amount of information, more predictions regarding the outcomes can be made. Clear and methodical records greatly benefit future healthcare practitioners or medical professionals in understanding better and treating the patient. Access to Medical Records The medical records are considered the rightful property of the medical practitioner of the patient or the hospital where the patient's treatment is taking place. The documents are completely confidential and cannot be released without the patient's consent. Every patient has the right to access their medical records and keep a copy of those said records. Other than them, the patient's legal representative and health care providers also have the authority to access the records. In the case of minors, the legal guardian or parents have the access. It is not an exaggeration to say that up-to-date and accurate medical records can save lives. Conclusion Thus, it can be easily concluded that medical records are a significant part of managing patients' healthcare. It is necessary for the doctors and other medical professionals to accurately maintain the records of all the patients under their care. Primarily it aids in the exact evaluation of the patients, understanding their health needs, and creating a proper treatment plan accordingly. Other than that, the legal system depends mostly on the evidence of such documents and is especially needed in medical negligence cases. Proper and accurate medical records are beneficial not only for the patients but also for the doctors and the whole medical industry. We offer medical coding classes which imparts the best medical coding training.
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