Medical record
Medical record
A Medical record (pronunciation: /ˈmɛdɪkəl ˈrɛkɔːrd/) is a systematic documentation of a patient's medical history and care. The term 'Medical record' is often used synonymously with Health record.
Etymology
The term 'Medical record' is derived from the Latin word 'medicus' meaning 'physician' and the Old French word 'record' meaning 'to recall, remember'.
Definition
A Medical record is a detailed written account of a patient's medical history, including symptoms, diagnoses, treatments, and outcomes. It may include information about allergies, medications, surgeries, and other medical events. Medical records are essential for providing comprehensive and coordinated care.
Importance
Medical records serve several important functions:
- They provide a basis for planning patient care and for the continuity of care.
- They serve as a communication tool among health care providers.
- They provide a legal document of the care provided.
- They support clinical research and health statistics.
Related Terms
- Electronic Medical Record (EMR): An electronic version of a patient's medical history.
- Personal Health Record (PHR): An electronic application used by patients to maintain and manage their health information.
- Health Information Exchange (HIE): The process of electronically sharing patient information between different health care organizations.
- Medical History: A record of information about a person's health, including past illnesses, surgeries, and treatments.
- Patient Portal: A secure online website that gives patients access to their health information.
See Also
External links
- Medical encyclopedia article on Medical record
- Wikipedia's article - Medical record
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