Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Regulating Health Care
Lecture:The Role of Medical Records in U.S. Health Care
Slide content:The Health Record Summarizes a patients health conditions and care activities Historically existed on paper but have become increasingly digitized Serves as a C ommunication and quality enhancement tool L egal record of the care provided 5
Slide notes:This lecture discusses the health record as a communication tool and legal document to demonstrate compliance with laws, rules, regulations, accreditation, and internal policies. Health records are documents that summarize a patients health conditions and care activities. Historically, health records were recorded on paper, but over the past few decades, health records have become increasingly digitized. The terms electronic medical record and electronic health record are largely synonymous, however, the use of the term electronic health record is frequently used to denote that the health record is multi-disciplinary in nature. The health record is, first and foremost, a tool for communication among members of the health care team. It is important that documentation in the health record be complete and accurate. When all components of the health record are used, such as clinical documentation, lab reports, x-rays, surgical reports, and consult reports, the patient has the best chance of receiving high-quality health care. Health IT Workforce Curriculum Version 4.0 5