A written or electronic account of a patient's medical history, current illness, diagnosis, details of treatments, chronological progress notes, and discharge recommendations. This is a legal document the patient is entitled to read and is authenticated by the physician's signature. There are strict rules regarding the confidentiality of the medical record.
A single, complete record kept at the site of the client's primary care provider that documents the medical services received by the client, including inpatient discharge summary, outpatient and emergency care.
the case history of a medical patient
a compilation of medical data relating to a patient
a complete and permanent documentation of a patient's history of illnesses and injuries and of all related medical treatments
an essential tool in providing continuity of care for all patients, regardless of the nature of the relationship between the physician and patient, and/or the frequency of patient encounters
All the medical information on a patient. The medical record includes patient discussions with the doctor, patient physical findings, laboratory tests, and doctor's interpretations of all this information.
A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care http://www.mckinley.uiuc.edu/clinics/medrec/medrec-faq.htmlhttp://www.physicianspractice.com/index.cfm?fuseaction=qa.details&QA_ID=342. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal.
