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headers of the contents section - I feel that the bullets do a little better job letting people know where things belong but think it would be nice to have something to quickly scan showing that demographics, progress notes, etc. all belong directly to contents. In any event, I'm not as qualified to change the administrative issues, though I believe they need quite a bit of work! It's difficult to tell what's the US and what's the UK. We should probably just divide up. Also, the EMR bit is not straight-forward. I might take a stab at it tomorrow...
1276:'the privacy of patients') replace 'it'? And then there is a sentence which says, "The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel.", but shouldn't the word 'implies' be 'applies', to make some sense (with the later change of 'in' to 'to'), so that the sentence would read, "The maintenance of the confidentiality and privacy of patients
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that *only* their own doctor can see them, not other doctors in the same practice or reception staff? Should patients have the right to anonymous health care? Personally, I hate the fact that doctors keep records about me, if I had a say in it, I'd have them burnt in 2 seconds flat. It also makes alternative health providers (like naturopaths, acupuncturists etc) seem a lot more attractive, because at least with them your anonymity is protected, and no records are kept.
1011:, so you can't just say 'it seldom happens'. You could say that different places define who has ownership differently. Or the sentence currently in the lead could be perhaps changed from, "Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.", to, "Although the storage equipment
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With immediatlty I mean that if I look at article's history, my edit was at 23:27, 7 July 2010, the reverting edit was at 23:27, 7 July 2010. How can an human user (the edit is not marked as made by a bot) read an edit, understand it in the context of the sentence and the nerby ones, decide that the
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I am not a doctor but I am familiar with a case where a doctor did not review the record prior to rendering treatment and this may have led to the death of a patient from pulmonary emboli. I stumbled on your article and just threw this out as a question because it was a question that I had and so I
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I agree - I like the idea of a clinical medical record and an administrative medical record division. This is a useful way to think about it. I think that the and be merged. However I think that there is some confusion about medical record/s/history because doctors tend to use words that are in
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All that needs be said about temperature on a page about medical records is to mention that there are four vital signs that are routinely recorded (temperature, respiratory rate, pulse, blood pressure), that temperature is one of them, and that "The patient's temperature is recorded at various times
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The "Media
Applied" section has a claim that implies that the Mayo Clinic invented a single-dosier medical record. This really needs a citation - I have placed a tag there, in the hopes that someone will find a citation.(I see the Mayo Clinic page itself says that the Clinic "Created an integrated
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Doctor's make their patient's medical records or their own medical record technician it depends some doctor's know how to make medical records some don;t so the point of a'medical record technician is to help the doctors with making their patient's medical records medicals are private and inportant
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Ceci Ă©tant dit, let us not overemphasize that there should be no confusion between them, either; specially if a specific context requires us to choose between one over the other when meaning could be comprimised if equivalence is not applicable interchangeably. Thus, I proposed one section on that,
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Thermocouples need direct contact with what the are to measure the temperature of and are not used by Ear thermometers which do not touch the ear drum. Ear thermometers instead use a device to measure infrared heat emmission. Thermocouples are though indeed found in electronic thermometers, but of
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to the beginning of the section? And the next sentence says, "Not only is it bound by the Code of Ethics...", but I wonder exactly what does 'it' refer to? Is it referring to HIPAA in particular, or
Privacy in general, or what? If it's Privacy in general, couldn't the word 'privacy'(or the phrase
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Currently there is a parochial template(I don't know what else it's called), informing readers that the
Privacy section is primarily about Privacy in the United States. Might it be appropriate to begin that section (until or if the section is improved to cover Privacy concerns in other places), by
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Could there be a section on ethical considerations? Eg, Should patients have the right to request that medical records not be kept? Should patients have the right to ask that medical records be destroyed? Should patients have more say over who gets to see their medical records, for instance saying
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I went ahead and made some additions, deletions, and formatting changes to the contents section. It seemed fairly jumbled to me and hopefully I made a dent in organizing it. I won't be offended if you think it's worse! I don't know if there's some easy way to make a box or something with the main
431:: the contents of an individual patient record, ie that it consists of has past history, current problems, correspondence and that each clinical encounter results in details of history, examination, investigations, diagnosis & treatments. It also contains social & family history etc etc.
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In
Australia, in general, the medical records held in a doctor's surgery/office are held to belong to the doctor, but the information contained belongs to the patient! In hospitals the medical record is the property of the hospital. Privacy legislation here means that although the record doesn't
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I don't know the answer to your question - how much of the medical record is the physician responsible for is a good question. Many medical records are veritable tomes - no one could be expected to have memorized them for each patient. That said, I'm sure that the legal system does! I'll put an
437:: the issue of medical records and accesibility to ones own notes, disclosure to others (ie confidentiality, legal requirements). Also issues of being comprehemnsive & contemparous and kept notes for many years to allow problems (education, audit, verification, disputes etc) to be managed.
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Thought this had been covered by the 'Purpose' section, but perhaps need to more explicitly state the legal implications of this ? There is a duty for anyone to "put themselves in a suitable position" to offer appropriate treatment. However need to think carefully on wording - a doctor in an
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The administrative portion is still quite messy. I've pretty much finished what I hoped to accomplish on the clinical side. I'm trying to research the various questions on the administrative side, but it's slow going. I think the whole section may benefit from a re-write and new structure.
445:. However careful redirection is needed between the two pages as 'Medical record' is so very close to 'Medical records'. Either that or rename them a 'Medical record (clinical)' and 'Medical records (administation)' with redirects from the current pages ? For now, much of the current
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The need to record temperature in the medical record is what is required in this article, not a full discussion on all different methods of measurement and their relative pros & cons. So I wanted to cut down on the fuller discussion (the article will get longer as other sections are
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the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel." (minus the bolding of the words)? I'm not comfortable just making those changes without some discussion, even though I think my changes make the sentence make better sense.
991:. You wrote, "Hence the should patient's record belongs to the patient, but it seldom happends.", and that sentence is both very poor English (you mentioned that English is not your native language, but this is an English language Wiki page), and also though what you wrote (that it
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I fixed it, making an edit, changing the sentence to 'Hence the should patient's record belongs to the patient, but it seldom happends.' (should = it should be, but not always is. It seldom = becouse it does not happend in any of the countries that were dealt in the article).
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Someone should change 'jurisdiction' to 'specialty' or 'area of expertise' or better yet 'discipline'. 'Jurisdiction' is a special word that means where the 'law can be spoken' and has nothing to do with whether a doctor under the law is seen as a legal provider of care.
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Emergency room has a duty to obtain info from the patient if concious, else attending 3rd parties if present, consider if need or time to contact the patient's usual physician (if known). But still possible will need to treat without any background information... -
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The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.
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Perhaps this depends upon the state or country. In my state, medical records are the legal property of the physician but the patient is legally entitled to a copy of anything in his or her record. Anyone monitoring this page who would care to comment?
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I know what MRN is: medical record number, but I swear I've heard other physicians say PF#... but I can't figure out what the acroyn for that might be. Anyone? Is there an article that addresses these abbreviations relating to the medical record?
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The history of the use of medical records is beyond the scope of this article. However a brief summary of the origins of the medical record in the West may be found at the following website: "History of medical record-keeping", Casebooks
Project
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belong to the patient, the patient's permission must be sought to release the information, to another doctor (for example taking over care) or to an insurance company, to the Roads and
Traffic Authority (for drivers licence information).
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medical record" but gives no details, and I don't think that the Clinic's own advert page can be used as a reliable citation.). In addition, there does not appear to be a logical reason why this claim is in the "Media
Applied" section.
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A lot of energy wasted upon discussing merging would be saved if a tree is used in the see also section. Illustration is given below. Editors are requested to the category page, and flesh out the tree. Suggest moving this tree to the
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tells about the
Minister of Health's suggestion for a law proposal: that doctors working at any particular office should have access to all the medical records that the other doctors there have written (while working
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Thanks for completing the tagging. Though, if you wish to create a separate article for the administrative structure behind medical records, I think you should create a more specific title than "medical records".
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I tend agree, but likewise for the whole paragraphs on blood pressure etc. Whilst each is well written and provides good overviews to the fuller topics (nice multiple links within WP), such should be under
999:, not a referenced fact (as required for Knowledge (XXG)). In corrected English, you might have meant, "Hence the patient's record should belong to the patient, but it seldom happens.", but the idea that
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Thermosensative material skin measurement is not primarily used in operative measurements (but thermocouple sensing is), rather they are sold in the tens of thousands as a simple children's thermometer
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the types used for oral, armpit or rectal recording. Thermocouples therefore have replaced glass mercury thermometers (now banned from use in Europe due to toxicity if the thermometer breaks open).
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This is 10 years late, and I can't 'ping' you so you could see it, but I'll say that the reverter was, I think, trying to tell you that he reverted it because the wording you put there
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I did a brief search and found multiple references from multiple States stating that the medical record belongs to the physician, but none stating it belongs to the patient
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they must be placed in a folder or a medical record case or a filing cabinet. to see medical records examples or forms or real medical records ask your doctor or go online.
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Is there a duty to review the medical record prior to treating the patient? What is the scope of the physicians or nurses duty? Should this be part of the article? -
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Major overhaul of the administrative portion. I still have a ways to go, though. Will continue to work on
Security, discussion of electronic record systems, etc. #
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What are you trying to state ? "comprimised if equivalence is not applicable" defeats me :-) I've reverted you edit for being uncited personal supposition (
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This record is a whole long write. I've tried to do it in several sittings; however, I decided to string out the headers and do some fill in afterward.
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page; please participate in the discussion there as the links being added here seem to be related and we can keep the discussion together. Thanks!
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Actually I can not understand why, "assuming in good fait", a good eit should be regarded as a "test edit". Why did the edit seem like a test?!
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As there appears to be no legitimate discussion or reason why these links are needed on the talk page, I am removing them here and elsewhere.
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I rewrote this section, partly to tidy english (eg "Prolonged elevated .....Prolonged depressions....") and partly as some inaccuracies.
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There had been stated 'Hence the patient's record belongs to the patient.', in the article's 'Informational self-determination' section.
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OK, seems consensus to merge (with info off to physical examination) - I'm happy to do this, and will do so over the next few days -
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When you have finished reviewing my changes, you may follow the instructions on the template below to fix any issues with the URLs.
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I agree that the articles should be merged. I like the idea of an eventual "clinical" and "administrative" division of the article.
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is not, I think, appropriate as neither ever will need be a full article and both can be encompassed in a single page (hence
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And couldn't the phrase, 'physical exploration' (in the sentence following the above mentioned one) be changed to 'physical
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for correcting my initial
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spent too much discussing other methods and so I simplified that too and place the additional info in a new article of
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during the day, so it can be examined for patterns which suggest fever." This is not the place to discuss methods. -
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http://www.magicandmedicine.hps.cam.ac.uk/on-astrological-medicine/further-reading/history-of-medical-record-keeping/
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record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request."
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So it's not true that 'the patient's record belongs to the patient', and there was an inconsistency in the article.
291:. I think that is sufficient to warrant the change right now, although maybe those outside the U.S. could comment.
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to delete these "External links modified" talk page sections if they want to de-clutter talk pages, but see the
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Yes, I would say merge them and move all the physical examination stuff to the physical examination article. --
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I agree with that, too. This article is getting much too detailed in areas it doesn't need to be.
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before doing mass systematic removals. This message is updated dynamically through the template
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e-mail out to our legal department tomorrow and will update the article with anything I find.
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In fact, I think it is now good enough to justify removing the cleanup tag, which I did. --
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How long are medical records kept in the US? I do not see this mentioned in the article.
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If you found an error with any archives or the URLs themselves, you can fix them with
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merged into this article; if you wish to see its history of edits then follow this
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I removed this. A better solution would be to actually write a history section.--
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that the editor had accidentally clicked "Save Page" instead of "Show Preview".
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edit should be reverted, and actually make the revert in less than a minute?
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The edit in question appeared to be a test edit, and was reverted as such.
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I think both aspects are sufficienty large that a single article would be
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I've tried to fix an inconsistency, but then the edit has been reverted
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I've edited this article to fix an inconsistency yesterday (
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In US: 'belongs to the patient', nut with "citation needed"
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for additional information. I made the following changes:
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The second sentence in the introductory paragraph states:
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But that edit was immediately reverted by another user.
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http://www.medicare.gov/Publications/Pubs/pdf/11397.pdf
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I think there should be no doubt that these 2 terms -
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Why? Is the article better with inconsistency in it?
792:What is the job outline for medical records clerk?
1203:using the archive tool instructions below. Editors
871:Actually, reading further on, it came out that:
457:articles should be edited as this weeks project?
707:About my new proposed definition - by: alo_world
723:hoping it will help clarify these discussions.
112:and that biomedical information in any article
1189:This message was posted before February 2018.
1003:is not exactly what the fact that it happens
582:It reads a lot better and looks a lot better
110:Manual of Style for medicine-related articles
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119:Knowledge (XXG) talk:WikiProject Medicine
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1047:— Preceding
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1016:
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40:WikiProjects
1005:differently
885:and so on.
794:—Preceding
730:—Preceding
727:alo_world
638:David Ruben
544:David Ruben
519:David Ruben
459:David Ruben
392:David Ruben
363:David Ruben
357:NB I thank
321:completed).
312:Temperature
1353:Categories
1267:stating, "
1252:Report bug
967:79.6.9.187
668:InvictaHOG
652:Bill Smoot
630:Bill Smoot
615:InvictaHOG
604:InvictaHOG
584:InvictaHOG
1235:this tool
1228:this tool
1139:Kmasters0
1107:Atlantima
1077:there).--
1013:and media
863:this edit
768:MRN vs PF
736:Alo world
554:Edwardian
507:Edwardian
483:Edwardian
324:Likewise
293:Edwardian
272:Edwardian
215:Una Smith
198:section
196:see also
1241:Cheers.—
1061:contribs
1049:unsigned
1017:facts on
844:Flowanda
830:Flowanda
796:unsigned
744:contribs
732:unsigned
447:WP:MCOTW
443:too long
429:Clinical
374:Nunh-huh
304:Lbandler
213:Done. --
125:Medicine
59:Medicine
1278:applies
1165:my edit
997:opinion
946:ANowlin
152:on the
30:B-class
1069:Norway
993:should
932:Huggle
757:WP:NOR
338:&
36:scale.
1009:means
694:Danny
235:DrGnu
1341:talk
1314:talk
1291:talk
1143:talk
1122:talk
1083:talk
1057:talk
1025:talk
971:talk
950:talk
916:talk
848:Talk
834:Talk
804:talk
779:talk
740:talk
715:and
698:talk
536:link
455:both
453:and
421:and
249:talk
229:This
219:talk
204:talk
1209:RfC
1179:to
144:Mid
1355::
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1282:to
1222:.
1217:}}
1213:{{
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944:--
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742:•
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574:WS
564:WS
498:WS
472:|
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1339:(
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1141:(
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1117:~
1114:âśż
1111:~
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468:-
346:)
247:(
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122:.
42::
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