What is "medical record"

n. Details about a patient's previous medical experiences, such as operations and medications taken.

n. the case history of a medical patient [syn: medical history, anamnesis]

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.

The terms are used for both the physical folder that exists 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. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association.

Because many consider the information in medical records to be sensitive personal 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. 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.

The Medical Record: A Weekly Journal of Medicine and Surgery was founded in 1866 by George Frederick Shrady, Sr. who was its first editor-in-chief. Thomas Lathrop Stedman became assistant editor in 1890 and editor-in-chief in 1897.

It was published in New York City. It was later published by the Washington Institute of Medicine.

Many issues of Medical Record are now in the public domain and available through the Google Books project.