1-4 Journal: Health Records - Critical Clinical Assignment

Health Records
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Health Records
Medical records are used to record and store critical clinical information and can either be on paper or digital. Marinič (2015) discusses that the health records ensure the proper health monitoring, treatment, and planning. The documentations include the consultation notes that the physician records during an appointment. Also, the admission records that contain the information regarding the reasons for one’s admission to the hospital. Another type of health record is the clinical documentation that includes personal information about the patient, lab results, treatments, and X-rays. Additionally, any correspondence relating to the care of the patient between them and the doctor or with other physicians are also part of the clinical records. The clinical records also have information concerning any transfers and details from the previous doctor if any, and patient’s history (Hayrinen, Sranto, & Nykanen, 2008). The discharge records are another kind that contains details of the patient’s treatment results and indicate if there are any further care or follow-ups are necessary.
The structuring of the electronic health records (EHR) varies from that of the paper-based record. According to Stausberg, Koch, Ingenerf, and Betzler (2003), the EHR has a formal structure with highly standardized data with controlled vocabulary. In comparison to the paper-based, EHR has a complicated design with component parts and their relationships. The records are segmented to store the different types of records including clinical, admission, and discharge documentations in large amounts. As a result of the structuring, it is easier to share and access full patient information using the EHR. Conversely, the paper-based records are less-structured or unstructured with text that is not controlled. There are no set standards concerning how to record data, unlike in the EHR system. Tsai and Bond (2007) explain that the information in paper-based systems is not organized hence it is difficult to get the details quickly or exchange with other caregivers.


References
Hayrinen, K., Sranto, K., & Nykanen, P. (2008). Definition, structure, content, use and impacts of electronic health records: A review of the research literature. Ijmedinfo. 77(5), 291-304.
Marinič, M. (2015). The Impor...