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:
... The federal Health Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy by providing medical information handling guidelines. ...
... 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 ...
... in treating extreme hypothermia has been chronicled in Cheating death the doctors and medical miracles that are saving lives against all odds by ...
... 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 ...
... 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:
“Human beings are compelled to live within a lie, but they can be compelled to do so only because they are in fact capable of living in this way. Therefore not only does the system alienate humanity, but at the same time alienated humanity supports this system as its own involuntary masterplan, as a degenerate image of its own degeneration, as a record of peoples own failure as individuals.”
—Václav Havel (b. 1936)
“They said Id never get you back again.
I tell you what youll never really know:
all the medical hypothesis
that explained my brain will never be as true as these
struck leaves letting go.”
—Anne Sexton (19281974)