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.
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?