Medical documents are physical collections of patient-related materials that include written notes and materials, graphs, test results, x rays, and other data.

Purpose

Medical documents have different purposes for the wellbeing care practitioner and the patient. The practitioner maintains documents to document individual contacts with the patient, to monitor the individual patient's wellbeing status, to comply with legal requirements, and to monitor the practitioner's own professional behaviors.

The patient uses his or her medical document to provide information to various wellbeing care providers and to maintain a knowledge of his or her own wellbeing care.

Description

Medical documents are created and maintained by wellbeing care professionals to supply medical practitioners with a sequential history of a patient's medical care and conditions affecting it. An individual's medical document is the collection of information that pertains solely to that person. It contains the information wellbeing care practitioners need to evaluate and treat the patient's wellbeing care needs. The document provides the patient's history of wellbeing care, past illnesses, test results, and other specific data.

Individual medical documents are confidential, except in cases where disclosure of its contents are required by law. Information contained in a patient's medical document cannot be released without the patient's written consent.

Operation

Medical documents are created by wellbeing care professionals and are an aid in the care of their patients. Specific information regarding a patient is contained in the documents. Contents of medical documents include wellbeing care professionals' notes about the patient, medical and social histories, physicians' assessments, x ray reports, the results of tests, and other materials specific to the healingof the patient. Materials may be provided to other wellbeing care professionals or hospitals only with the patient's written consent.

Maintenance

Medical documents are maintained by physicians, physician assistants, nurses, and medical documents clerks. Only authorized personnel can make entries in the document.

Wellbeing care team roles

Key Terms

Term

DefinitionKey Terms

Apprenticeship

Training a person who is new to the particular work being done, can also be on-the-job training.

Confidential

In medicine, implies a mutual trust between the patient and wellbeing care practitioner.

Medical history

Information about the patient's past medical services, procedures, illnesses, and needs.

Practitioner

Someone who engages in the science of medicine.

Social history

Information about the patient's past social needs and services utilized.

Wellbeing care professionals are required to keep accurate documents. Information is documented every time the patient is seen by a wellbeing care practitioner. Findings of each practitioner who treats the patient documents are documented in the appropriate section of the document.

Training

Wellbeing care practitioners receive training in keeping accurate medical documents in several different ways, including:

  • training during medical or nursing school

  • classes at a vocational or business school

  • apprenticeship or on-the-job training