What is a medical note?
A medical note is an entry into a medical or health record made by a physician, nurse, lab technician or any other member of a patient’s healthcare team. Accurate and complete medical notes ensure systematic documentation of a patient’s medical history, diagnosis, treatment and care.
What kind of information comprises a medical note?
Ideally, health care providers will enter medical notes to record every medically relevant event that has happened to a patient since birth. Events include diseases, major and minor illnesses, and growth landmarks. The notes should give any clinician reading a patient’s medical record an understanding of everything that has occurred previously to the patient. This is crucial to help healthcare providers diagnose current disease states.
These notes include:
- Surgical history (e.g., operation dates, operation reports, operation narratives)
- Obstetric history: (e.g., pregnancies, any complications, pregnancy outcomes)
- Medications and medical allergies
- Family History (e.g., immediate family member health status, cause of death, common family diseases)
- Social History (e.g., community support, close relationships, past and current occupation)
- Habits (e.g., smoking, alcohol consumption, exercise, diet, sexual history)
- Immunization Records (e.g., vaccinations, immunoglobulin test)
- Developmental History (e.g., growth chart, motor development, cognitive/intellectual development, social-emotional development, language development)
- Demographics (e.g., race, age, religion, occupation, contact information)
- Medical encounters (e.g., hospital admissions, specialist consultations, routine checkups)
During a medical encounter, medical charts will include any and all summations relevant to the patient’s care, including:
- Chief complaint
- History of the present illness
- Physical examination (e.g., vital signs, muscle power, organ system examinations)
- Assessment and plan (e.g., diagnosis, treatment).
- Orders and prescriptions
- Progress notes
- Test results (e.g., imaging results, pathology results, specialized testing)
Who has access to medical charts and notes?
Only the patient and the health care providers directly involved in her or his care can view a medical chart. The medical chart belongs to the patient, and she or he has the right to make sure the charts are accurate or grant another party access to them. Patients can petition their providers for amendments to inaccurate medical charts.
How an Electronic Health Record can help
An electronic health record, or EHR, is set up to ensure that medical charts are complete and accurate. Think of it as a digital version of a patient’s paper medical chart. With good EHR software and EHR systems, health care providers will be alerted to any missing, incomplete, or possibly inaccurate medical charts.
An EHR is a real-time record that makes health information available instantly and securely to authorized users. EHRs are built to share medical notes with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all involved in a patient’s care. This has the potential to automate and streamline health provider workflow.
The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting. An EHR also guarantees a patient’s medical chart is never lost and stored in one easy to access location.
Compared to paper records, the use of EHRs can improve patient care tremendously. They can:
Reduce the incidence of medical error by improving the accuracy and clarity of medical records and coordination of diagnosis and treatment among health providers
Make the health information instantly accessible, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
Allow patients to log on to her own record and see lifetime health trends to be better informed about their health.