Analysis of Medical Records and their Role in Healthcare Management

This report delves into the crucial role of medical records in healthcare, emphasizing their significance in patient care and treatment planning. It highlights how medical records, encompassing patient history, diagnoses, and lab results, serve as vital tools for clinicians to understand a patient's medical journey, enabling informed decisions and effective treatment strategies. The report discusses the evolution of medical records, from paper-based systems to electronic medical records, and their impact on healthcare delivery, including the challenges and benefits associated with their use. It also explores the impact of documentation on reimbursement policies and the need for accurate, legible records. By examining the long-standing views of Korzybski, the report asserts that medical records are a legitimate representation of a patient's medical condition, forming the basis for treatment and improving patient outcomes. The report also addresses the current concerns surrounding documentation, advocating for solutions to improve the accuracy and efficiency of medical record-keeping to enhance patient care and streamline healthcare operations. The report concludes by referencing relevant research and literature to support its findings.

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Medical records are important to healthcare staff and physicians to learn in a short
time the patient’s medical care history. This enables them to understand current diagnosis,
prior care so as to be able to come up with a treatment plan for the patient. In patient care,
clinicians deem medical records as vital tools. They contain patients self reported information,
diagnoses notes from physicians, care, lab tests, biographical data, other medical conditions,
preventive therapies and earlier treatments. Therefore, these records help clinicians to know
where the patient is going by understanding where they have been. It acts as a roadmap in the
patients’ treatment more so to subsequent physicians to provide the best possible care to the
patient.
The long standing views of Korzybski that ‘the map is not the territory’ and ‘the
representation of reality is not reality itself’ are not legitimate in this situation because the
patient’s medical records represent every bit of the medical condition the patient is in. It is
this records that are used to formulate a treatment plan for the patients. Therefore, whatever is
in the medical record is legitimate otherwise patients could not be getting better from their
ailments after treatment. Medical records contain the reality of a patient’s illness. The
information recorded is gotten from past records, diagnosis, observations and lab tests making
it real. Medical records do not just embody patients’ medical history but also forms a basis for
treatment.
Contemporary medical records are meant to aid cognition, create a comprehensive and
continuous account of care, communicate and support the patients’ long term care. They help
in creating medical decisions and relationships and at the same time decrease workload.
Documentation of Medicare is overtaking care delivery in terms of perceived
importance, clinician focus and time. Medical records are used to provide evidence to backup
patient care aspects and for evaluation purposes to enhance the services quality. The records
have been used for research to improve, guide performance, as a legal record and support
making of decisions. All these uses tend to shift clinician attention more to appropriate record
keeping other than focusing all the attention to patient communications and narratives.
Medical records use in reimbursement policy coarse providers to document services legibly,
accurately and completely for the third parties that are mostly insurers. This increase the
lengthy of the records in HIMs in a bid to communicate to set standards by insures which in
providing care services are not helpful. However, these should be done to enable claims
settlement easy even though it strains service providers. Concerns of compliance and time
constraints have created poor documentation as a current monster in medical records;
however it can be easily solved by eliminating the causes.

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References
Bleich, H. L., & Slack, W. V. (2010). Reflections on electronic medical records: when doctors
will use them and when they will not. International journal of medical informatics,
79(1), 1-4.
Boonstra, A., & Broekhuis, M. (2010). Barriers to the acceptance of electronic medical
records by physicians from systematic review to taxonomy and interventions. BMC
health services research, 10(1), 231.
Chapnick, P. (1989). The Map is Not the Territory. ETC: A Review of General Semantics,
352-354.
Leung, R. S. (2013). The map is not the territory.
Urbanik, B. A. (2012). The Map is Not the Territory (Master's thesis, University of Waterloo).