Records
Records (Medicine)
Records (pronunciation: /ˈrekərdz/) in the context of medicine, refer to the systematic documentation of a patient's medical history and care over time within a health care provider's jurisdiction.
Etymology
The term 'record' originates from the Latin word 'recordari' which means 'to remember'. In the medical context, it refers to the act of maintaining a written account of a patient's health history and treatment.
Types of Medical Records
There are several types of medical records, each serving a specific purpose:
- Electronic Health Records (EHRs): These are digital versions of the paper charts in clinician offices, hospitals, and health facilities. They contain information about a patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results.
- Personal Health Records (PHRs): These are health records where the data is maintained by the patient. They can provide a complete and accurate summary of the individual's medical history which can be shared with doctors and other healthcare providers.
- Medical History Records: These records contain a detailed account of the patient's past and present health status. They include information about the patient's personal habits, lifestyle, and even the health of family members.
Importance of Medical Records
Medical records serve several important functions in the healthcare system:
- They provide a basis for planning patient care and for the continuity of care.
- They serve as a means of communication among the many health professionals who contribute to the patient's care.
- They assist in protecting the legal interest of the patient, the healthcare providers responsible for the patient's care, and the healthcare facility itself.
Related Terms
- Health Information Management: This is the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care.
- Medical Coding: This is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
- Medical Billing: This is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider.
External links
- Medical encyclopedia article on Records
- Wikipedia's article - Records
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