18 Nov Types of Medical Records: A Complete Guide
Types of Medical Records: A Complete Guide
Medical records come in many shapes and sizes, and they’re used in a plethora of ways depending on who is requesting them and for what reasons. Understanding these functions starts with appreciating what types of medical records there are and what roles they play.
Below, we’ll provide an overview of what medical records are, why they matter, common types of medical records, and how they’re used in certain industries. We’ll also cover challenges people face in accessing medical records and how working with medical record retrieval services can help.
What Are Medical Records and Why Do They Matter?
Medical records document healthcare interactions between patients and caregivers. Any time an individual receives care from a practitioner, hospital, or other provider, medical records are generated. Accurate descriptions of conditions, treatments, medications, and billing help care provision and business operations, along with later legal or insurance investigations.
Researchers have found overwhelming evidence of the value medical records provide, especially electronic records. They support better health outcomes and make healthcare operations more efficient, which leads to cost savings that can benefit all stakeholders.
But to provide maximum value, these records need to be accurate, with infrastructure in place to both secure them and make them easily retrievable by all authorized parties. Additionally, modern technology like AI in medical records retrieval has become a powerful tool for speeding up access and improving accuracy across healthcare and legal settings.
Common Types of Medical Records
Healthcare operations generate many different types of medical records. Some of the most common kinds relate to inpatient and outpatient services, including but not limited to:
- Documentation of medical history
- Notes generated during a patient visit
- Records of procedures performed
- Records of treatments prescribed
- Detailed test results and analysis
- Discharge summaries after stays
- Billing for services rendered
The biggest difference between inpatient and outpatient records is comprehensiveness. An outpatient record pertains to ambulatory services and is generally narrower in scope, while inpatient records pertain to stays in facilities and generally have more ground to cover. Each form of record often carries a unique number or identifier that ensures accurate filing within the right system and department, making retrieval and updates easier when correction or additional entry is required.
Another distinction to keep in mind is the difference between electronic medical records (EMR) and electronic health records (EHR). While the names are nearly identical, EMRs are maintained by single healthcare providers and focus on the specific services they provide. EHRs are maintained across multiple healthcare providers and are generally more holistic and comprehensive, with each digit of the identifying code tied to the designated patient.
Legal and Insurance Use Cases for Different Record Types
Two of the biggest use cases for medical records outside of healthcare provision itself are in law and insurance: Law firms and insurers use personal medical records to deliver the best results for clients.
Medical record retrieval for lawyers powers many key legal functions.
- Documentation of patient visits can corroborate claims about conditions and injuries
- Transcripts of procedures can help prove (or disprove) medical malpractice
- Billing records can be triangulated with treatment and other medical record documentation to sort out liability disputes between various parties
Similarly, medical record retrieval for insurance companies powers fast, fair, and accurate decision-making. Swift and easy access to medical records allows insurers to validate claims and assess coverage, whereas bottlenecks in retrieval processes can cause costly delays.
Challenges in Accessing and Organizing Medical Records
Although nearly all healthcare interactions produce medical records, and all healthcare providers can be expected to have huge collections thereof, it can often be difficult to obtain medical records.
On one level, there are few hard and fast rules about uniformity. Healthcare providers of different kinds and in disparate locations may format and store records in very different ways. In addition, medical records can be siloed as a side effect of regulatory measures. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) places strong restrictions on whether and how protected health information (PHI) can be shared under its Privacy and Security Rules.
These protections extend to how medical records are stored, meaning that HIPAA compliance can challenge patients’ access to records, even though it necessitates it.
On another level entirely, there are also general logistical challenges of communication and coordination between individuals who do not know or work with each other regularly. Delays and inconsistencies should be expected, unless there is significant infrastructure in place to review and reconcile records across different offices or practice settings.
How Retrieval Partners Simplifies Access to Medical Records
Having a centralized, streamlined retrieval process in place eliminates many of the challenges of medical record retrieval—and mitigates any difficulties that are unavoidable outright. With communications pipelines in place, medical records retrieval solutions providers take the guesswork and groundwork out of retrieval, delivering documents swiftly and easily.
Quality medical records retrieval partners also cover all compliance bases. Strong HIPAA protections prevent unauthorized uses and disclosures, per the HIPAA Privacy Rule, with de-identification and safeguarded storage options to satisfy the HIPAA Security Rule.
Most importantly, sound medical record retrieval processes ensure faster turnarounds, reducing delays in case preparation and claim processing and minimizing costs for all parties.
The Value of Understanding Medical Record Types
Understanding what types of medical records there are and the different roles they can play helps law firms and insurers support stronger cases and claims, respectively. Appreciating how accuracy and timeliness matter also highlights the value of effective record retrieval.
Professionals seeking medical records, for whatever reason, should work with reliable records retrieval partners to minimize bottlenecks and maximize clients’ outcomes.
Consider American Retrieval for comprehensive access to all medical record types.
Sources:
Forbes. EHR Vs. EMR: What’s The Difference? https://www.forbes.com/advisor/business/software/ehr-vs-emr/
HIPAA Journal. HIPAA Compliance and Medical Records. https://www.hipaajournal.com/hipaa-compliance-and-medical-records/
National Library of Medicine. Value of the Electronic Medical Record for Hospital Care: Update From the Literature. https://pmc.ncbi.nlm.nih.gov/articles/PMC8738989/
