Medical Records

Medical records are also referred to as health records and refer to a systematic documentation of a patient’s medical history and care across time within a health care provider’s jurisdiction. It is a longitudinal record of what has happened to the patient since birth and chronicles diseases, major and minor illnesses, as well as growth landmarks. The record also includes a variety of types of notes recorded over time by the health care professionals treating the patient, test results, X-rays, magnetic resonance imaging’s, recording observations of drugs and therapies, and other reports. The maintenance of complete and accurate medical records is mandatory for health care providers in most developed countries and is generally obligatory as a licensing or certification prerequisite.

Medical records have traditionally been collected ...