Uses of Hospital Records
- Only designated personnel and the patient can access a hospital record.Hospital Files image by PinkSony from Fotolia.com
A hospital record is a documentation file that is created when a patient first visits a hospital. This file contains a patient's medical history and any notes a physician has deemed important. The information contained in each folder allows the record to have a variety of uses including serving as courtroom evidence and as factor to provide quality and continuity of service. - Hospital records are useful in sexual assault cases because they detail a victim's past medical history and provide vital information for convictions or acquittals. The information provided in a hospital record is updated by a doctor every time a person is admitted to the hospital. When an assault victim is admitted, the record will describe the amount of damage a victim has suffered after a doctor has examined her for any bruising, cuts or signs of struggle. The record will also contain information on whether there is reason to doubt a victim's story due to past psychological problems. In either case, courts use this information to corroborate testimony during a trial. Doctors may be called in as witnesses to verify the information on the record.
- Hospital records are important for providing doctor accountability. Each state's department of health requires doctors, licensed or certified, to actively maintain medical records for every patient. Records are updated every time a doctor sees a patient. Doctors must list the original assessment, diagnosis, proposed treatment and any other relevant reference note. The purpose of this process is to provide suitable reasoning for doctor action. Should a malpractice action occur, the hospital record will provide a court with further information on what went wrong or whether a doctor had reason to perform a treatment.
- Doctors can provide continuity of care to patients by having an up-to-date hospital record. This is important for patients that are examined by different doctors and nurses each time they visit. Doctors and nurses can read a patient's history and be readily updated on a his current status so that redundancy and mistakes do not occur. This results in a continuity of service for the patient, leaving him confident that another doctor can pick up where the last one left off.
Hospital records are also helpful for patients who are fortunate to be examined by the same doctor each time they visit. These type of doctors are often single practitioners who must examine a variety of patients throughout their practice. Having an updated hospital record allows the doctor to remember the results of past examinations and continue her service to the patient without losing time.
