A written document that contains sufficient information to identify the patient clearly, to justify the diagnosis and treatment, and to document the results accurately.
A record kept on patients which properly contains sufficient information to identify the patient clearly, to justify his diagnosis and treatment, and to document the results accurately. The purposes of the record are to serve as the basis for planning and continuity of patient care; provide a means of communication among physicians and any professional contributing to the patient’s care; furnish documentary evidence of the patient’s course of illness and treatment; serve as a basis for review, study, and evaluation; serve in protecting the legal interests of the patient, hospital, and responsible practitioner; and provide data for use in research and education. Medical records and their content of the record is usually confidential. Each different provider in a community caring for a given patient usually keeps an independent record of that care.
Information about a person’s medical history.
A file kept for each patient, maintained by the hospital (the physician also maintains a medical record in his own practice), which documents the patient’s problems, diagnostic procedures, treatment, and outcome. Related documents, such as written consent for surgery and other procedures, are also included in the record. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) places great importance on the medical record in the accreditation process, and its Accreditation Manual for Hospitals (AMH) contains an extensive description of the desired and required contents of the medical record.
A detailed accounting of a person’s health status over time. Medical records include information about vital signs, illnesses, injuries, test results, diagnoses, and treatments. Other pertinent information such as allergies to medications is also included. Medical records are confidential documents protected by federal law.
The information recorded and kept on paper or electronically by health professionals about an individual’s illness(es). The information is normally available only to those responsible for caring for the patient and to the patient, if he or she should wish to see it.
A written transcript of information obtained from a patient, guardian, or medical professionals concerning a patient’s health history, diagnostic tests, diagnoses, treatment, and prognosis.