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The role of medical records in the humanisation of medicine

7 September 2023

Medicine, as a field of science and practice, requires precision, meticulousness and accountability. A key role in this context is played by medical documentation, which is an essential part of the management of the treatment process and patient care. However, in the context of modern medicine, which increasingly pays attention to the humanisation of its approach, medical documentation does not only have an administrative role. It is also a key element in enabling health services to be provided according to the principle of 'patient first'.

Medical records: definition and purpose

Medical records include all types of records that are created during the provision of health services, whether on paper or electronically. It includes information about the patient's condition, diagnoses, treatment plans, reactions to medication, test results, as well as notes about meetings with the patient and concerns or preferences expressed by the patient.

The purpose of medical records is multiple. On a practical level, it serves to maintain continuity of care, support clinical decisions and coordinate between different health services. But from the point of view of the humanisation of medicine, medical records have another, equally important purpose.

Medical records and the humanisation of medicine

Humanising medicine means providing healthcare that respects patient autonomy, empowers patients and pays attention to their individual experiences, values and needs. In this context, medical records play a key role.

Firstly, the medical record is where the patient is 'visible' in the healthcare system. The information it contains about the patient is not limited to symptoms and diagnoses, but also includes the patient's personal experiences, preferences and values. For example, information about a patient's beliefs about treatment, concerns about side effects or preferences for end-of-life care can be important for clinical decision-making and care planning.

Secondly, the medical record enables communication between different health services. It communicates information not only about the patient's condition, but also about who the patient is as a person. This allows the different members of the healthcare team to better understand the patient and adapt their actions to the patient's individual needs.

Thirdly, medical records are a tool to enable patients to participate in decisions about their health. By having access to their medical records, patients can better understand their illnesses and treatment, ask questions, express their concerns and participate in decision-making.

Developing medical records towards the humanisation of medicine

The patient-centred medical record thus becomes a tool that transcends the purely technical perspective of medicine. It becomes a platform where each patient is treated as an individual, and where their preferences, experiences and values have a real impact on the treatment process.

However, further developments are needed to make the most of these opportunities. Doctors and other health professionals need to be adequately trained to acquire skills related to documenting psychosocial aspects of the patient. Medical record systems must be properly designed and adapted to enable such records. Patients also need to be educated about their right to access their medical records and how they can actively participate in the documentation process.

Medical records and patient rights

Ensuring that patients have access to their medical records is also an important aspect of the humanisation of medicine. This is particularly important in the context of patients' rights. The patient has the right to be fully informed about his or her state of health and the course of treatment. Access to medical records enables the patient to influence the treatment process and to make informed decisions about their health.

In the perspective of the development of medicine, which is becoming increasingly complex and specialised, the role of medical documentation as a tool for humanisation cannot be overestimated. Medical documentation, by enabling the patient to actively participate in the treatment process, contributes to the transformation of the model of medicine towards a holistic approach, where the patient is not only a recipient of health services, but a full partner in the treatment process. It is this model of medicine, which takes into account the patient's individual experience, values and needs, that can bring the greatest benefits to patients and the healthcare system as a whole.