Medical Records

A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care. The term 'Medical Record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal. Although medical records are traditionally compiled and stored by health care providers, Personal Health Records (PHR) maintained by individual patients are now the wave of the future.

Many people consider information about their health to be highly sensitive, deserving of the strongest protection under the law. Long-standing laws in many states and the age-old tradition of doctor-patient privilege have been the mainstay of privacy protection for decades.

Now, the federal Health Insurance Portability and Accountability Act (HIPAA) sets a national standard for privacy of health information, effective April 14, 2003. But HIPAA only applies to medical records maintained by health care providers, health plans, and health clearinghouses - and only if the facility maintains and transmits records in electronic form. A great deal of health-related information exists outside of health care facilities and the files of health plans, and thus beyond the reach of HIPAA. (PRC Fact Sheet 8a, "HIPAA Basics," www.privacyrights.org/fs/fs8a-hipaa.htm.

The CSI Managed Health System now offers creation of Medical Records in electronic form, commonly known as PHRs.