The healthcare professionals provide a window for clinical judgement. The presence of an updated, accurate, and complete medical record can make a lot of difference. Medical Record is a relevant record made by a health care professional at the time of or later on the examination and consultation of the patient. It covers a wide range of documents, which are generated due to patient care.
It includes the following:
- Hand-written notes were taken by a medical practitioner
- Referral letters from health care practitioners
- Notes by previous practitioners who have attended health care practitioners including a typed discharge summary of patients.
- Laboratory reports and laboratory evidence including histology sections, X-ray reports and films, cytology slides, and ECG traces.
- Clinical trial data and clinical research forms
- Other forms such as insurance forms, documents of injury, and disability assessments.
The Importance of Medical Records for Research
Research is vital and it benefits all, whether we are healthy or we are suffering from any kind of illness. Research can help to understand the prevention, causes, treatment of diseases and improving health care.
When you visit a doctor, your health record is automatically updated. The record has important information regarding your well being and health and states that care, which you have received. This is essential for medical research.
Research using medical records has provided evidence regarding drug safety and improved healthcare. Many public health studies are published using this data. Researchers have used data for clinical studies from the early days of recordkeeping. Using Electronic Health Records data for research is known as a secondary use. Initially, the data was collected for patient care and secondarily for research. Before the use of electronic data, this data was abstracted manually from clinical documents to make secondary use.
With an electronic query, you can get data from thousands of patients within a few minutes. This makes the researchers answer scientific and clinical questions efficiently and quickly at a much lower cost. The researchers should show that this data is sufficient for supporting their conclusions. The important is discussed in details in our help for assignment on Medical Records Research.