Record

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Record (Medicine)

Record (pronounced: /ˈrɛkərd/), in the context of medicine, refers to a systematic documentation of a patient's medical history and care. The term comes from the Latin word 'recordari' which means 'to remember'.

Overview

A medical record is created by the healthcare provider and can include a variety of information such as the patient's history, physical examination findings, diagnostic test results, medications, and other pertinent healthcare information.

Types of Medical Records

There are several types of medical records, including:

  • Medical Histories - These are a record of information about a patient's past and present health.

Importance of Medical Records

Medical records serve many purposes, including:

  • Providing a basis for planning patient care and for the continuity of care.
  • Serving as a legal document outlining the care received.
  • Verifying services and treatments for third-party payers.

See Also

References

  • Medical Records Manual: A Guide for Developing Countries. World Health Organization. 2006.

External links

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