Medical Records in Texas

Medical Records in Texas

Introduction

In its simplest form, a medical patient record is a document stored in a machine-readable format. Data are entered into the record via many different sources, including computerised entry and various document imaging systems. (Carter, 2001) The record should include electronic documentation of information normally included in a paper record regarding a specific patient. The ideal electronic patient record should reflect the same information that is typically found in the classic paper record, with variance according to provider as well as patient. The record is typically stored on a computer or server and is accessible to anyone having access to the file. The key feature is accessibility via a machine such as a computer.

Data stored in a medical record can be as simple as an image of the paper record such as is available through many different scanning utilities. Reasons one might consider a simple electronic representation of a paper record include such things as decreasing storage space, increasing security of the record, and ease of access to a specific record. This type of record, although useful, has obvious limitations and likely has associated cost that will not provide substantial return on investment. Increasing utility is achieved by adding searchable fields to the record, allowing the searcher to find specific elements in the record itself. Records that store data in specific fields capable of being indexed, tracked, and searched can dramatically improve care for the patient and increase return on investment. This potential improvement in care has led to an ever increasing interest in electronic medical records.

Texas

In Texas, the advances in electronic records include systems that support users by storing data in databases that are coded and structured to allow easy retrieval by stakeholders for patient care delivery, management, decision support, and analysis. Some (including the Institute of Medicine) refer to these advanced records as computer-based patient records. The ideal electronic medical record is still being defined but should include minimum elements such as a complete recording of historical items related to a particular patient's care, stored in a database with defined values as opposed to narrative value that is not as searchable. It should also be easily accessible and improve efficiency of record taking. The ideal medical record will eventually be compatible with data management instead of just data collection and should be planned with management as the goal.

Data recording without management capacity will handicap the ability of health care to improve itself. All quality control efforts require application of scientific method to data rather than just to collection of data. Electronic patient record designs should allow investigators to evaluate groups of diseases and conditions with their various characteristics and treatments. This will allow more standardisation of medical care, leading to more consistent and error-free care. To such end, all records should be planned with database evaluation as an ultimate goal. (Chang et al., 2004)

Electronic patient records should provide an integrated view of information needed regarding a specific patient's care (Carter, ...