img

Medical Records

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. The medical record includes a variety of types of "notes" entered over time by health care 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.