Primary Purpose of a Medical Record
Are we losing sight of the primary purpose of a patient medical record, which is to support patient care?
Narrative notes serve several purposes by helping physicians and other caregivers:
- Decide upon the appropriate course of care and provide rationale
- Create context for a patient’s story, and make one patient memorable from the next
- Provide continuity of care over time and among clinicians
- Communicate with referring and consulting colleagues
The most important part of the medical record is the physician’s narrative note, which documents the thought process for why a course of treatment is decided upon after each patient encounter. Narrative notes also provide a useful summary of the other information contained in a medical record, such as the results of labs, imaging and other diagnostic tests.
Over time, the medical record has been commandeered for other purposes, most notably as a legal record of care provided and as the basis for insurance billing and payment.
Although clinical documentation plays a central role in EHRs and occupies a substantial proportion of physicians’ time, documentation practices have largely been dictated by billing and legal requirements. Yet the primary role of documentation should be to clearly describe and communicate what is going on with the patient.
Gordon Schiff, MD & David Bates, MD -- NEJM 25 Mar 2010
Gordon Schiff, MD & David Bates, MD -- NEJM 25 Mar 2010
The paper medical record has been able to maintain its integrity as a patient care document while accommodating billing and legal requirements. However, as we move to electronic medical records, are we losing sight of its primary purpose?
