Abstract
This chapter provides a brief history of health records development through the ages, from ancient Mesopotamian clay tablets through to today's electronic health record. An understanding of where we have come from informs future direction and enhances knowledge. While the content and method has evolved, the need to document health information has been consistent for over 4000 years. The central premise has always been to support quality health care through quality information. This chapter will explore the link between health records and patient safety.
TopHistory Of Health Records
Health records are used by clinicians when delivering care to patients. They are the repository of information from past presentations and the current episodes of care which is then used to plan future care. Health records now contain a vast amount of information on individual people, but this was not always the case. This section focusses on samples from history and highlights the features that are still present today in records.
Key Terms in this Chapter
Health Record: A term used to describe the collection information generated to record the clinical care and health status of an individual or group. Health records are also known as medical records, paper-based health records, clinical records, healthcare records, digitized health records, electronic health records, electronic medical records, and personal health records.
Personal Health Record: Health records controlled by the individual but contain information from a variety of providers. PHRs can contain diagnosis, medications, immunisations, medical history and contact information.
Patient: The traditional term of ‘patient’ is used to represent people who are in receipt of health services. Other terms of ‘client’ and ‘consumer’ are used within the healthcare environment.
Health Information: Data related to a person’s medical history, including symptoms, observations, treatments, diagnoses, procedures, and outcomes. Health information records include patient histories, diagnostic investigations, clinical information, and notes.
Health Information Management Professionals: The health information management professional applies their knowledge and skills to create, acquire, analyse and/or manage information to meet the medical, legal, ethical and/or administrative requirements of the health care system.
Adverse Event: An unintended event which causes harm to a patient. Examples include falls, hospital acquired complications, infections, and medication errors.
Patient Safety: Is the absence or minimisation of accidental injury or preventable harm to patients while receiving healthcare. This term also covers the action.
Digital Health: The connecting of health information at points of care using digital technology with the aim to improve individual health and wellbeing. Digital health includes product such as electronic health records, electronic medical records, personal health records and health apps.
Information: Is data that has been organised and processed to provide meaning.
Electronic Medical Record (EMR): Digitised version of paper health records and forms. Information may be captured on paper, then digitised through a scanning process and have information directly entered. EMRs contain assessments, treatment records, progress notes and other information associated with providing care for single healthcare organisation.
Electronic Health Record (EHR): Digitised information as well as information that is directly entered (born digital) or interfaced from other systems. EHRs contain information for all providers involved in the patient’s care and can included information from multiple healthcare facilities.
Healthcare Professional: Overarching term used to capture different professions involved in delivering health care including, but not limited to, medical, nursing, pharmacy, and allied health.
Documentation: Is the official account of care, treatment and interventions made by clinicians and logged in the health record.
Data: Is raw, unorganised individual elements or facts. These can be numbers, symbols, text, or images.
Australian Digital Health Authority (ADHA): An Australian Government department tasked with improving health outcomes for Australians through the delivery of digital healthcare systems and the national digital health strategy for Australia.
Privacy: The right of individuals for their information to be kept secure and confidential. Information is only disclosed when appropriate to do so such as providing ongoing care or when lawfully required.