Medical Records Research Paper

The continuous improvement of technology has also paved way to debates among medical facilities whether to convert their medical records into electronic records or not. Both manual and electronic way of storing medical records has its own advantages and not. As old medical facilities have been keeping numerous paper records, it will be costly for them to convert all of these to electronic records. New medical facilities may find it easier to convert venture into electronic medical records compared to the old facilities. In terms of storage and legibility and access, electronic recording has the edge. This is due to the obvious reasons that electronic records do not require filing cabinets to save the records because small storage devices can take their places. Likewise, doctors are known for having “hard to decipher” penmanship, thus saving the records in electronic format would be more readable and of course, it is easier to search electronic records compare to piles and piles of folders. In terms of security, they are on the same level because they both need physical security. (Csiszar, 2013)
The convention for filling out medical records is to start with the lastname and firstname plus the birthdate of a person. All documents like the patient’s history, current treatments and diagnosis, laboratory results and correspondence are included in the medical records of a person. The first type of medical record stored is the patients past records. This record contains the historical information on the patients past office visits, diagnosis and treatments and other records. It is very important to secure these information because these are confidential. Another type of medical records is a record used by heath care facilities to make their medical charts. This is called the Subjective, Objective, Assessment and Plan or the SOAP. It contains information of the patient’s present condition, his objective status, the diagnosis made and the treatments or planned treatments. Operative Report is still another medical record containing details about an operation made to a patient like specimens. Laboratory Results are still another type of medical record which contains results of laboratory results and other clinical specimens. (Garret, 2011)
There are several medical records but handling them requires extreme care as unauthorized released of medical records are against the law. (WHO, 2012)

Works Cited:

Cisizar, John (2013). Paper vs Electronic Medical Records. smallbusiness.chron.com. Web. N.a. 11 Jan 2015.
Garret, Peter (2011). EMR vs EHR – What is the Difference? Web. January 4, 2011. 11 Jan 2015
WHO (2012). Electronic Health Records: Manual for Developing Countries. Web. N.a. 11 Jan 2015.
WHO (n.a.) Medical Records Manual. Web. N.a. 11 Jan 2015.