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The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.[1] The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.

 

The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.

 

Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites.[2] This concept is supported by US national health administration entities[3] and by AHIMA, the American Health Information Management Association.[4]

 

A medical record folder being pulled from the records

 

Because many consider information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal.[5] Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.

 

The history of the use of medical records is beyond the scope of this article. However a brief summary of the origins of the medical record in the West may be found at the following website: "History of medical record-keeping", Casebooks Project (http://www.magicandmedicine.hps.cam.ac.uk/on-astrological-medicine/further-reading/history-of-medical-record-keeping/) (Accessed 2012-09-25).

 

Purpose

 

The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.

 

The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.

 

 

Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.[6]

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Auxiliary purpose

 

In addition, the individual medical record anonymised may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research and development.

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Contents

 

A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient.[7] Further information varies with the individual medical history of the patient.

 

The contents are written by medical providers, and patients until relatively recently had no say in what was contained in it. Recent advances in health care records privacy and access rules have generally provided for a patient's right to review and have recorded in the medical record objections to the accuracy of certain entries.

 

The medical history or (medical) case history (also called anamnesis, especially historically)[1][2][3] (abbr. Hx) of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

 

The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.

Ана́мнез (от греч. ἀνάμνησις — воспоминание) — совокупность сведений, получаемых при медицинском обследовании путём расспроса самого обследуемого и/или знающих его лиц. Изучение анамнеза, как и расспрос в целом, не просто перечень вопросов и ответов на них. От стиля беседы врача и больного зависит та психологическая совместимость, которая во многом определяет конечную цель — облегчение состояния пациента.

 

Данные анамнеза (сведения о развитии болезни, условиях жизни, перенесённых заболеваниях, операциях, травмах, беременностях, хронической патологии, аллергических реакциях, наследственности и др.) медицинский работник выясняет с целью их использования для диагностики, выбора метода лечения и/или профилактики. Сбор анамнеза является одним из основных методов медицинских исследований. В некоторых случаях, в совокупности с общим осмотром, он позволяет точно поставить диагноз без дальнейших диагностических процедур. Сбор анамнеза — это универсальный метод диагностики, применяемый во всех областях медицины

Сбор анамнеза – первый этап в установлении диагноза. Это неотъемлемая часть врачебного искусства, которая определяется прежде всего личностью врача.

 

Curricula are usually divided into preclinical sciences, where students study subjects such as biochemistry, genetics, pharmacology, pathology, anatomy and physiology, among others, and clinical rotations, which usually include internal medicine, general surgery, pediatrics, psychiatry, and obstetrics and gynecology, among others.

 

Admission to medical school in the United States is based mainly on a GPA, MCAT score, admissions essay, interview, clinical work experience, and volunteering activities, along with research and leadership roles in an applicant's history. While obtaining an undergraduate degree is not an explicit requirement for a few medical schools, virtually all admitted students have earned at least a bachelor's degree. A few medical schools offer pre-admittance to students directly from high-school by linking a joint 3-year accelerated undergraduate degree and a standard 4-year medical degree with certain undergraduate universities, sometimes referred to as a "7-year program", where the student receives a bachelor's degree after their first year in medical school.

 

As undergraduates, students must complete a series of prerequisites, consisting of biology, physics, and chemistry (general chemistry and organic). Many medical schools have additional requirements including calculus, genetics, statistics, biochemistry, English, and/or humanities classes. In addition to meeting the pre-medical requirements, medical school applicants must take and report their scores on the MCAT, a standardized test that measures a student's knowledge of the sciences and the English language. Some students apply for medical school following their third year of undergraduate education while others pursue advanced degrees or other careers prior to applying for medical school.

 

In the nineteenth century, there were over four hundred medical schools in the United States. By 1910, the number was reduced to one hundred and forty-eight medical schools and by 1930 the number totaled only seventy-six. Many early medical schools were criticized for not sufficiently preparing their students for medical professions, leading to the creation of the American Medical Association in 1847 for the purpose of self-regulation of the profession. Abraham Flexner (who in 1910 released the Flexner report with the Carnegie Foundation), the Rockefeller Foundation and the AMA are credited with laying the groundwork for what is now known as the modern medical curriculum.[10]

 

The standard U.S. medical school curriculum is four years long. Traditionally, the first two years are composed mainly of classroom basic sciences education, while the last two years primarily include rotations in clinical settings where students learn patient care firsthand. Today, clinical education is still spread across all four years, with the final years being more heavily weighted towards clinical rotations.

 

Upon successful completion of medical school, students are granted the title of Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.). Residency training, which is a supervised training period of three to seven years (usually incorporating the 1st year internship), is typically completed for specific areas of specialty. Physicians who sub-specialize or who desire more supervised experience may complete a fellowship, which is an additional one to four years of supervised training in their area of expertise.

 

Unlike many other countries, US medical students finance their education with personal debt. In 1992, the average debt of a medical doctor after residency was $25,000. For the class of 2009, the average debt of a medical student is $157,990 and 25.1% of students had debt in excess of $200,000 (prior to residency).[11] For the past decade the cost of attendance has increased 5-6% each year (roughly 1.6 to 2.1 times inflation).[12]

 

Licensing of medical doctors in the United States is co-ordinated at the state level. Most states require that prospective licensees complete the following requirements:

Graduation from an accredited medical school granting the degree of D.O. or M.D.

United States and Canada schools must be accredited by the American Association of Colleges of Osteopathic Medicine or the Liaison Committee on Medical Education.

Foreign medical school graduates generally must complete some training within the United States.

Satisfactory completion of at least one year of an AOA- or ACGME-approved residency.

Passing the United States Medical Licensing Examination or the Comprehensive Osteopathic Medical Licensing Examination (USMLE, COMLEX, or simply "the boards"). USMLE and COMLEX both consist of four similar parts:

Step I is taken at the end of the second year of medical school and tests students' mastery of the basic sciences as they apply to medicine.

Step II CK is taken during the fourth year of medical school and tests students' mastery of the management of ill patients.

Step II CS is taken during the fourth year of medical school and tests students' mastery of clinical skills using a series of standardized patient encounters.

Step III is taken after the first year of a residency program and tests physicians' ability to independently manage the care of patients.

 

Medicine (i/ˈmɛdsɨn/, i/ˈmɛdɨsɨn/) is the applied science or practice of the diagnosis, treatment, and prevention of disease.[1] It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness in human beings.

 

Contemporary medicine applies health science, biomedical research, and medical technology to diagnose and treat injury and disease, typically through medication or surgery, but also through therapies as diverse as psychotherapy, external splints & traction, prostheses, biologics, ionizing radiation and others.

 

The word medicine is derived from the Latin ars medicina, meaning the art of healing.[2][3]

 

In clinical practice, doctors personally assess patients in order to diagnose, treat, and prevent disease using clinical judgment. The doctor-patient relationship typically begins an interaction with an examination of the patient's medical history and medical record, followed a medical interview[4] and a physical examination. Basic diagnostic medical devices (e.g. stethoscope, tongue depressor) are typically used. After examination for signs and interviewing for symptoms, the doctor may order medical tests (e.g. blood tests), take a biopsy, or prescribe pharmaceutical drugs or other therapies. Differential diagnosis methods help to rule out conditions based on the information provided. During the encounter, properly informing the patient of all relevant facts is an important part of the relationship and the development of trust. The medical encounter is then documented in the medical record, which is a legal document in many jurisdictions.[5] Followups may be shorter but follow the same general procedure.

 

The components of the medical interview[4] and encounter are:

Chief complaint (cc): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'presenting complaint.'

History of present illness / complaint (HPI): the chronological order of events of symptoms and further clarification of each symptom.

Current activity: occupation, hobbies, what the patient actually does.

Medications (Rx): what drugs the patient takes including prescribed, over-the-counter, and home remedies, as well as alternative and herbal medicines/herbal remedies. Allergies are also recorded.

Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.

Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).

Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.

Review of systems (ROS) or systems inquiry: a set of additional questions to ask, which may be missed on HPI: a general enquiry (have you noticed any weight loss, change in sleep quality, fevers, lumps and bumps? etc.), followed by questions on the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc.).

 

The physical examination is the examination of the patient looking for signs of disease ('Symptoms' are what the patient volunteers, 'Signs' are what the healthcare provider detects by examination). The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (e.g., in infection, uremia, diabetic ketoacidosis). Taste has been made redundant by the availability of modern lab tests. Four actions are taught as the basis of physical examination: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen). This order may be modified depending on the main focus of the examination (e.g., a joint may be examined by simply "look, feel, move". Having this set order is an educational tool that encourages practitioners to be systematic in their approach and refrain from using tools such as the stethoscope before they have fully evaluated the other modalities).

 

The clinical examination involves study of:

Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation

General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing)

Skin

Head, eye, ear, nose, and throat (HEENT)

Cardiovascular (heart and blood vessels)

Respiratory (large airways and lungs)

Abdomen and rectum

Genitalia (and pregnancy if the patient is or could be pregnant)

Musculoskeletal (including spine and extremities)

Neurological (consciousness, awareness, brain, vision, cranial nerves, spinal cord and peripheral nerves)

Psychiatric (orientation, mental state, evidence of abnormal perception or thought).

 

It is to likely focus on areas of interest highlighted in the medical history and may not include everything listed above.

 

Laboratory and imaging studies results may be obtained, if necessary.

 

The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.

 

The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.

 

This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.

 

On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results or specialist consultations.

 

 

Contemporary medicine is in general conducted within health care systems. Legal, credentialing and financing frameworks are established by individual governments, augmented on occasion by international organizations. The characteristics of any given health care system have significant impact on the way medical care is provided.

 

Advanced industrial countries (with the exception of the United States)[6][7] and many developing countries provide medical services through a system of universal health care that aims to guarantee care for all through a single-payer health care system, or compulsory private or co-operative health insurance. This is intended to ensure that the entire population has access to medical care on the basis of need rather than ability to pay. Delivery may be via private medical practices or by state-owned hospitals and clinics, or by charities, most commonly by a combination of all three.

 

Most tribal societies, and the United States,[6][7] provide no guarantee of healthcare for the population as a whole. In such societies, healthcare is available to those that can afford to pay for it or have self-insured it (either directly or as part of an employment contract) or who may be covered by care financed by the government or tribe directly.

 

Modern drug ampoules

 

Transparency of information is another factor defining a delivery system. Access to information on conditions, treatments, quality, and pricing greatly affects the choice by patients/consumers and, therefore, the incentives of medical professionals. While the US healthcare system has come under fire for lack of openness,[8] new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other.

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Delivery

See also: Health care, clinic, hospital, and hospice

 

Provision of medical care is classified into primary, secondary, and tertiary care categories.

 

Primary care medical services are provided by physicians, physician assistants, nurse practitioners, or other health professionals who have first contact with a patient seeking medical treatment or care. These occur in physician offices, clinics, nursing homes, schools, home visits, and other places close to patients. About 90% of medical visits can be treated by the primary care provider. These include treatment of acute and chronic illnesses, preventive care and health education for all ages and both sexes.

 

Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists. These include both ambulatory care and inpatient services, emergency rooms, intensive care medicine, surgery services, physical therapy, labor and delivery, endoscopy units, diagnostic laboratory and medical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting.

 

Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals. These include trauma centers, burn treatment centers, advanced neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology, etc.

 

Modern medical care also depends on information – still delivered in many health care settings on paper records, but increasingly nowadays by electronic means.

 

The University of Birmingham offers courses in medicine and dentistry and has high-quality laboratories and clinical research facilities in the University Hospital Birmingham Foundation Trust building.

Durham employs modern teaching methods and the latest technologies to deliver service-relevant medical training for undergraduates.

The Peninsula Medical School's Life Science Research Center is a special area and facility that introduces students to the structure and functionality of the human body. This helps in facilitating a faster learning process for students.

It offers small group academic and clinical teaching.The school has graduate and post-graduate courses and offers research degree and post-graduate courses for working doctors and senior health professionals.

 

The Bashkirian Medical University was founded in 1932. It was one of the first educational institutions in the Republic and played an important role in the development of higher education, science, culture and training of highly qualified specialists in Bashkiria. For more than twenty years the University had only one faculty, that of General Medicine. At present, it is composed of the faculties of General Medicine, Pediatrics, Dentistry, Pharmacy, Nursing, Health Protection, Microbiology and Social Activities. Besides, there are refresher courses for physicians.

The students of the University attend classes and lectures, perform laboratory experiments and conduct research in a variety of health disciplines. Training is based on scientific principles. Lectures on theory are combined with practical classes in every subject. There are all the facilities for the students to combine studies with research work.

Postgraduate programmes are under way in most departments.

The University has a large academic staff. Professors, lecturers and assistants work for more than 70 chairs of the University. The University has educated most of the doctors, dentists, and pharmacists currently practicing within the Republic of Bashkortostan and Russian Federation.

 







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