Management of Patient Records

Patient records are documents that contain information about the patient's clinical findings, history, medication and progress, diagnostic test results, and pre-operative and post-operative treatment (Nelson, 2008). Patient records or data, if collected and managed correctly, can assist doctors and physicians in determining the accuracy of treatment. The management of patient data is one of the most crucial components of health care, on which almost every medical struggle is won or lost (Devkota & Buerck, 2012). This paper examines several health care data sets, focusing on their types and collection, uses, and significance in distinct health care contexts. Hospital based acute care forms a primary component of the health service continuum in any part of the world as it provides treatment for a broad range of diseases or severe illness episodes for short periods (Nelson, 2008). The goal of acute care is to discharge patients as soon as they receive the desired treatments and become stable and healthy. The information collected under acute care include patient’s average length of stay, casualty attendances, diagnostic records, and live birth records among others (Nelson, 2008).

The acute care dataset has both primary and secondary functions. The main function of acute care data set is to provide support to direct patient care by forming the basis of evidence for the clinicians, as well as supporting various clinical decision-making processes and offering effective means of communication between the clinicians and the patients (Devkota & Buerck, 2012). On the other hand, the acute care data set plays a secondary role of providing legal care records and acting as a source of information for supporting research, clinical audit, performance monitoring, resource allocation, as well as epidemiology and service planning (Devkota & Buerck, 2012). Effective and efficient management of acute care records is necessary for the improvement of quality and safety of medical services and practice.

Ambulatory Care Data Set

An ambulatory care data set refers to electronically stored information of a patient's outpatient health records, which includes data relating to surgeries and all forms of care records that do not involve admission to a health care facility (Devkota & Buerck, 2012). The ambulatory care data set also include the records of health services provided in non-hospital settings such as medical practitioners' offices, urgent care clinics, and at-home medical care. All the ambulatory care data are readily accessible to doctors and all other medical professionals, and they help the physicians in viewing the patients' accurate and complete medical history (Devkota & Buerck, 2012).

Long-Term Care Data Set

The Long-term care data set forms a primary screening and standardized assessment tool for the patients' health status. It forms the foundation of the patients' comprehensive assessment, and it involves the collection of information relating to the patients' clinical, physical, psycho-social, and psychological functioning, as well as their life care needs (Nelson, 2008).

All the patients, especially those in rehabilitation facilities undergo long-term care assessment during admission, quarterly, annually, as well as when faced with significant changes in health status (Nelson, 2008). The long-term care data set is useful in monitoring the quality and performance of nursing homes. Besides, it has a broad application in medical research and can be integrated with other Medicare records to give accurate and reliable information regarding the patient's health condition (Nelson, 2008).

Additionally, long-term care data set play an essential role in contributing significantly towards meeting the medical and non-medical needs of individuals with a disability or chronic illnesses who cannot take care of themselves for long periods (Devkota & Buerck, 2012). The collection of long-term care data aims at achieving efficient coordinated and individualized services that promote maximum patients' life quality and independence, as well as meet the patients' needs over a given period. However, since the long-term care facilities' residents may stay for an extended period in such facilities, the management of the long-term care data set may be a challenging task for the medical record practitioners (Nelson, 2008).

Home Health Care Data Set

Home health care entails a broad range of health care services that can be offered in individual’s home in case of injury or illness. The collection of home health care data set is usually more convenient, less expensive, and just as effective as those collected from a hospital setting or using a skilled nursing facility (Nelson, 2008). Some of the home health care data include the patients' eating and drinking habits, blood pressure, breathing condition, temperature, pulse rate, adherence to prescriptions, as well as body pain conditions. Others include the patients' safety, and frequency of communication with the caregivers (Nelson, 2008). The primary goal of collecting home health care data set is to ensure that the patients receive proper treatments of their illnesses and injuries while at home. Besides, home health care data set contributes significantly to helping patients get better, regain their independence, as well as become self-sufficient (Nelson, 2008).


The management of patient records is an essential practice to all healthcare activities and forms part of the medical practitioners' statutory and ethical duty in offering good patient care. The collection of accurate and quality patient records is necessary for patients' proper continuous care and is essential for effective communication between the patients and healthcare professionals. It is, therefore, advisable for the all the care providers to continuously update the patients' medical records in chronological order for effective management and to demonstrate efficient care continuity and response to treatment. Besides, the patient records should always be comprehensive enough to allow medical practitioners to carry on from where the previous clinicians left.


Devkota, B., & Buerck, J. (2012). Electronic health records and products recall management for patient safety in health care. Health Renaissance, 10(2).

Nelson, J. (2008). Personal Health Records. Home Health Care Management & Practice, 21(2), 141-142.

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