What is medical record?

Medical Record

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.

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Some articles on medical record:

Medical Record - Privacy
... The federal Health Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy by providing medical information handling guidelines. ...
The Medical Transcription Process
... time with the former discussing his medical problems, including history and/or problems ... office, the doctor uses a voice-recording device to record the information about the patient encounter ... This report is then accessed by a medical transcriptionist, it is clearly received as a voice file or cassette recording, who then listens to the dictation and transcribes it into ...
Mads Gilbert - Medical Record
... in treating extreme hypothermia has been chronicled in Cheating death the doctors and medical miracles that are saving lives against all odds by ...
List Of Open-source Healthcare Software - Categories - Electronic Health or Medical Record
... alphabetical order) FreeMED is a practice management and electronic and computer records system ... It allows the tracking of medical data, in detail, with preservation not just of the diagnosis but the reasons for medical encounters ... GNU Health (aka "Medical") is a free, centralized, highly scalable health and hospital information system Hospital OS Open source hospital information system in Thai ...
Entity–attribute–value Model - History of EAV Database Systems
... The first medical record systems to employ EAV were the Regenstrief electronic medical record (the effort led by Clement MacDonald), William Stead and Ed Hammond's TMR (The ... cannot be overestimated.) A group at the Columbia-Presbyterian Medical Center were the first to use a relational database engine as the foundation of an EAV system ...

Famous quotes containing the words record and/or medical:

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