This article is about the documentation of a patient's medical history. For digital records, see electronic health record. For the New York journal published by the Washington Institute of Medicine, see Medical Record (journal). For the BBC Radio 4 medical programme, see Case Notes (radio show).
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.[1] A medical record includes a variety of types of "notes" entered over time by healthcare 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.
The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites.[2] This concept is supported by US national health administration entities[3] and by AHIMA, the American Health Information Management Association.[4]
A medical record folder being pulled from the records
Because many consider the information in medical records to be sensitive private information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal.[5] Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.[6]
^"Personal Health Records" (PDF). CMS. April 2011. Archived from the original (PDF) on 2012-03-05. Retrieved 2012-04-14.
^"Frequently Asked Questions". MyPHR.com. Archived from the original on 2012-04-11. Retrieved 2012-04-14.
^"National Institute for Health". Nih.gov. Retrieved 2012-04-14.
^"American Health Information Management Association". Ahima.org. 2012-03-22. Retrieved 2012-04-14.
^"Health Information Privacy". Hhs.gov. Retrieved 2012-04-14.
^"10 tips to give patients electronic access to their medical records". American Medical Association. 9 March 2020.
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