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Medical record
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==Uses== The information contained in the medical record allows [[health care providers]] to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation. The traditional medical record for inpatient care can include [[admission note]]s, [[on-service note]]s, [[progress note]]s ([[SOAP note]]s), [[preoperative note]]s, [[operative note]]s, [[postoperative note]]s, [[procedure note]]s, [[delivery note]]s, [[postpartum note]]s, and [[discharge note]]s. [[Personal health record]]s combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.<ref>{{cite web|url=http://www.mckinley.illinois.edu/units/medical_records/medical_records.htm |title=Medical Records |publisher=McKinley Health Center |access-date=2012-04-14}}</ref> Electronic medical records could also be studied to quantify disease burdens β such as the number of deaths from [[antimicrobial resistance]]<ref>{{cite journal |author=Christopher JL Murray |display-authors=et al. |title=Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis |journal=The Lancet |date=12 February 2022 |volume=399 |issue=10325 |pages=629β655 |doi=10.1016/S0140-6736(21)02724-0 |pmid=35065702 |pmc=8841637 |language=English |issn=0140-6736}}</ref> β or help identify causes of, factors of and contributors to diseases,<ref>{{cite journal |last1=Solomon |first1=Daniel H. |last2=Liu |first2=Chih-Chin |last3=Kuo |first3=I.-Hsin |last4=Zak |first4=Agnes |last5=Kim |first5=Seoyoung C. |title=Effects of colchicine on risk of cardiovascular events and mortality among patients with gout: a cohort study using electronic medical records linked with Medicare claims |journal=Annals of the Rheumatic Diseases |date=1 September 2016 |volume=75 |issue=9 |pages=1674β1679 |doi=10.1136/annrheumdis-2015-207984 |pmid=26582823 |pmc=5049504 |language=en |issn=0003-4967}}</ref><ref>{{cite journal |last1=Newschaffer |first1=Craig J. |last2=Bush |first2=Trudy L. |last3=Penberthy |first3=Lynne T. |title=Comorbidity measurement in elderly female breast cancer patients with administrative and medical records data |journal=Journal of Clinical Epidemiology |date=1 June 1997 |volume=50 |issue=6 |pages=725β733 |doi=10.1016/S0895-4356(97)00050-4 |pmid=9250271 |language=en |issn=0895-4356}}</ref> especially when combined with [[genome-wide association study|genome-wide association studies]].<ref>{{cite journal |last1=Byun |first1=Jinyoung |last2=Schwartz |first2=Ann G |last3=Lusk |first3=Christine |last4=Wenzlaff |first4=Angela S |last5=de Andrade |first5=Mariza |last6=Mandal |first6=Diptasri |last7=Gaba |first7=Colette |last8=Yang |first8=Ping |last9=You |first9=Ming |last10=Kupert |first10=Elena Y |last11=Anderson |first11=Marshall W |last12=Han |first12=Younghun |last13=Li |first13=Yafang |last14=Qian |first14=David |last15=Stilp |first15=Adrienne |last16=Laurie |first16=Cathy |last17=Nelson |first17=Sarah |last18=Zheng |first18=Wenying |last19=Hung |first19=Rayjean J |last20=Gaborieau |first20=Valerie |last21=Mckay |first21=James |last22=Brennan |first22=Paul |last23=Caporaso |first23=Neil E |last24=Landi |first24=Maria Teresa |last25=Wu |first25=Xifeng |last26=McLaughlin |first26=John R |last27=Brhane |first27=Yonathan |last28=BossΓ© |first28=Yohan |last29=Pinney |first29=Susan M |last30=Bailey-Wilson |first30=Joan E |last31=Amos |first31=Christopher I |title=Genome-wide association study of familial lung cancer |journal=Carcinogenesis |date=21 September 2018 |volume=39 |issue=9 |pages=1135β1140 |doi=10.1093/carcin/bgy080|pmid=29924316 |pmc=6148967 }}</ref><ref name="10.1073/pnas.0911686107"/> For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized<ref>{{cite journal |last1=Al-Zubaidie |first1=Mishall |last2=Zhang |first2=Zhongwei |last3=Zhang |first3=Ji |title=PAX: Using Pseudonymization and Anonymization to Protect Patients' Identities and Data in the Healthcare System |journal=International Journal of Environmental Research and Public Health |date=January 2019 |volume=16 |issue=9 |page=1490 |doi=10.3390/ijerph16091490 |pmid=31035551 |pmc=6540163 |language=en |issn=1660-4601|doi-access=free }}</ref> forms to ensure patients' privacy is maintained.<ref>{{cite journal |last1=Tamersoy |first1=Acar |last2=Loukides |first2=Grigorios |last3=Nergiz |first3=Mehmet Ercan |last4=Saygin |first4=Yucel |last5=Malin |first5=Bradley |title=Anonymization of Longitudinal Electronic Medical Records |journal=IEEE Transactions on Information Technology in Biomedicine |date=May 2012 |volume=16 |issue=3 |pages=413β423 |doi=10.1109/TITB.2012.2185850 |pmid=22287248 |pmc=3779068 |issn=1558-0032}}</ref><ref name="10.1073/pnas.0911686107">{{cite journal |last1=Loukides |first1=Grigorios |last2=Gkoulalas-Divanis |first2=Aris |last3=Malin |first3=Bradley |title=Anonymization of electronic medical records for validating genome-wide association studies |journal=Proceedings of the National Academy of Sciences |date=27 April 2010 |volume=107 |issue=17 |pages=7898β7903 |doi=10.1073/pnas.0911686107 |pmid=20385806 |pmc=2867915 |bibcode=2010PNAS..107.7898L |language=en |issn=0027-8424|doi-access=free }}</ref><ref>{{cite journal |last1=Chevrier |first1=RaphaΓ«l |last2=Foufi |first2=Vasiliki |last3=Gaudet-Blavignac |first3=Christophe |last4=Robert |first4=Arnaud |last5=Lovis |first5=Christian |title=Use and Understanding of Anonymization and De-Identification in the Biomedical Literature: Scoping Review |journal=Journal of Medical Internet Research |date=31 May 2019 |volume=21 |issue=5 |pages=e13484 |doi=10.2196/13484 |pmid=31152528 |pmc=6658290 |language=EN |doi-access=free }}</ref><ref>{{cite journal |last1=Puri |first1=Vartika |last2=Sachdeva |first2=Shelly |last3=Kaur |first3=Parmeet |title=Privacy preserving publication of relational and transaction data: Survey on the anonymization of patient data |journal=Computer Science Review |date=1 May 2019 |volume=32 |pages=45β61 |doi=10.1016/j.cosrev.2019.02.001 |s2cid=133142770 |language=en |issn=1574-0137}}</ref>
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