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School of Paramedical Sciences
Mashhad University of Medical Sciences
A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care. 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. Although medical records are traditionallycompiled and stored by health care providers, personal health records maintained by individual patients have become more popular in recent years.
Purpose
The information contained in the medical record allows health care providers to provide continuity of care to individual patients. The medical record also serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care, assisting in protecting the legal interest
of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient. In addition, the medical record may serve as a document to educate medical students/resident physicians, toprovide data for internal hospital auditingand quality assurance, and to provide data for medical research. Personal health recordscombine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.
Format
Traditionally, medicals records have been written on paper and kept in folders. These folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues. Active records are usually housed at the clinical site, but older records (e.g. those of the deceased) are often kept in separate facilities.
The advent of electronic medical records has changed not only the format of medicalrecords, but has increased accessibility of files.
Medical history
The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states.
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Faculty of Health & Paramedicine Mashhad University of Medical Sciences medical record introduction Last Update : 2012-02-09 04:33:17
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Faculty of Paramedical
