Record
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:
- Electronic Health Records (EHRs) - These are digital versions of the paper charts in clinician offices, hospitals, and other healthcare facilities.
- Personal Health Records (PHRs) - These are health records where the data is maintained by the patient.
- 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
- Medical encyclopedia article on Record
- Wikipedia's article - Record
This WikiMD dictionary article is a stub. You can help make it a full article.
Languages: - East Asian
中文,
日本,
한국어,
South Asian
हिन्दी,
Urdu,
বাংলা,
తెలుగు,
தமிழ்,
ಕನ್ನಡ,
Southeast Asian
Indonesian,
Vietnamese,
Thai,
မြန်မာဘာသာ,
European
español,
Deutsch,
français,
русский,
português do Brasil,
Italian,
polski