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NJHA Library & Links
Frequently Asked Questions (FAQs)
Hospital, Patient and Medical Records: FAQs
Prepared by: J. Harold Johnston Memorial Library New Jersey Hospital Association.Below are brief answers to the library's most frequently asked questions relating to medical records. All e-mail from patients and consumers, including those to the NJHA Library, must use the e-form NJHA Contact Us. E-mail received in other ways will be redirected to this form for an NJHA response. Library and other non-consumer requests may contact the NJHA Library at (609) 275-4130.
This document highlights FAQ and answers regarding hospital records, patient records and medical records.
Medical RecordA medical record is defined as "A file kept for each patient, maintained by the hospital (physicians also maintain medical records in their own practices), which documents the patient's problems, diagnostic procedures, treatment, and outcome. Related documents, such as written consent for surgery and other procedures, are also included in the record. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) places great importance on the medical record in the accreditation process, and its Accreditation Manual for Hospitals (AMH) contains an extensive description of the desired and required contents of the medical record. Ordinarily the record is kept on paper, but it is increasingly being kept in computer (electronic) media as computer-based patient records (CPR). Occasionally a hospital keeps a separate medical record for each hospitalization (hospital admission); the better practice is to use the "unit record system," that is, keep a "unit record" for each patient, with all records of the patient's successive hospitalizations in the patient's unit file. The record itself is usually organized in either the "traditional" or the clinical record, the patient's chart, or simply the chart."
[Source: Slee's Health Care Terms, 3rd Edition.]
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