Definition Of Health Records

Health records contain demographic data next of kin gp details and most of the following.

Definition of health records. Health record synonyms health record pronunciation health record translation english dictionary definition of health record. As used in the uk a health record is a collection of clinical information pertaining to a patient s physical and mental health compiled from different sources. While an ehr does contain the medical and treatment histories of patients an ehr system is built to go beyond standard clinical data collected in. An electronic health record ehr is a digital version of a patient s paper chart.

A record is a phr if. A legal health record lhr is the documentation of patient health information that is created by a health care organization. Treatment including surgical. In medicine or dentistry a chronologic written account that includes a patient s initial complaint s and medical history physical findings results of diagnostic tests and procedures any therapeutic medicines or procedures and subsequent developments during the course of the illness.

For the bbc radio 4 medical programme see case notes radio show. The data kept in a phr varies from one person to another and from one system to another but information in a typical record might include. A personal health record or phr is an electronic application through which patients can maintain and manage their health information and that of others for whom they are authorized in a private secure and confidential environment. Ehrs are real time patient centered records that make information available instantly and securely to authorized users.

It s secure usable and online it s managed by the person who the record is about and they can add information to their phr it stores information about that person s health care and wellbeing. Medical record the case history of a medical patient as recalled by the patient anamnesis medical history case history detailed record of the. 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. A personal health record phr is a collection of health related information that is documented and maintained by the individual it pertains to.

Information about visits to healthcare professionals.