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.
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 notes, on-service notes,
progress notes (SOAP notes), preoperative notes, operative notes,
postoperative notes, procedure notes, delivery notes, and discharge
notes.
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.Recently i have found more information medical records on
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