Editing Medical record (section)

{{short description|Medical term}}
{{About|the documentation of a patient's medical history|digital records|electronic health record|the New York journal published by the Washington Institute of Medicine|Medical Record (journal)|the BBC Radio 4 medical programme|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 [[health care|care]] across time within one particular health care provider's jurisdiction.<ref>{{cite web |url=http://www.medicare.gov/Publications/Pubs/pdf/11397.pdf |title=Personal Health Records |publisher=CMS |date=April 2011 |access-date=2012-04-14 |url-status=dead |archive-url=https://web.archive.org/web/20120305221931/http://www.medicare.gov/Publications/Pubs/pdf/11397.pdf |archive-date=2012-03-05 }}</ref> A medical record includes a variety of types of "notes" entered over time by [[healthcare professional]]s, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, [[X-ray]]s, 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 record]]s (PHR) that are maintained by patients themselves, often on third-party websites.<ref>{{cite web |url=http://www.myphr.com/resources/faqs.aspx |title=Frequently Asked Questions |publisher=MyPHR.com |access-date=2012-04-14 |archive-url=https://web.archive.org/web/20120411042219/http://www.myphr.com/resources/faqs.aspx |archive-date=2012-04-11 |url-status=dead }}</ref> This concept is supported by US national health administration entities<ref>{{cite web|url=http://www.nih.gov/ |title=National Institute for Health |publisher=Nih.gov |access-date=2012-04-14}}</ref> and by [[AHIMA]], the American Health Information Management Association.<ref>{{cite web|url=http://www.ahima.org/ |title=American Health Information Management Association |publisher=Ahima.org |date=2012-03-22 |access-date=2012-04-14}}</ref>
[[File:US Navy 041019-N-5821P-019 Airman Lauren Thurgood of Las Vegas, Nev., pulls patient medical records in the inpatient ward aboard the conventionally powered aircraft carrier USS Kitty Hawk.jpg|300px|thumb|right|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.<ref>{{cite web|url=https://www.hhs.gov/ocr/privacy/ |title=Health Information Privacy |publisher=Hhs.gov |access-date=2012-04-14}}</ref> 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.<ref>{{cite web|title=10 tips to give patients electronic access to their medical records|publisher=American Medical Association|date=9 March 2020|url=https://www.ama-assn.org/practice-management/hipaa/10-tips-give-patients-electronic-access-their-medical-records}}</ref>