Record

Record (medicine)

A medical record is a systematic documentation of a patient's medical history and care. It is created by healthcare professionals and often includes a variety of data compiled over the course of a patient's treatment.

Overview

Medical records serve as a basis for planning patient care, for documenting communication among the patient's health care provider coordinating team, and for documenting services and billing information. They include information such as demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information.

Types of Medical Records

There are several types of medical records, including:

• Electronic Medical Records (EMRs): These are digital versions of the paper charts in clinician offices, clinics, and hospitals. EMRs contain notes and information collected by and for the clinicians in that office, clinic, or hospital and are mostly used by providers for diagnosis and treatment.

• Electronic Health Records (EHRs): EHRs are a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

• Personal Health Records (PHRs): PHRs are health records where health data and information related to the care of a patient is maintained by the patient.

Importance of Medical Records

Medical records are essential for patient care, as they provide a written history of a patient's interactions with the health care system and can be crucial in medical decision making. They can also be used for research, quality management, legal purposes, and to satisfy policy requirements.

See Also

• Health informatics
• Medical privacy
• Health Insurance Portability and Accountability Act
• Electronic health record

References

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