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  2. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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.

  3. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    They are the repository of medical facts and clinical thinking, and are intended to be a concise vehicle of communication about a patient’s condition to those who access the health record. The majority of the medical record consists of progress notes documenting the care delivered and the clinical events relevant to diagnosis and treatment ...

  4. Operative report - Wikipedia

    en.wikipedia.org/wiki/Operative_report

    The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...

  5. From passwords to medical records,10 things to never say to ...

    www.aol.com/passwords-medical-records-10-things...

    Medical or health data: AI isn’t Health Insurance Portability and Accountability Act-compliant, so redact your name and other identifying info if you ask AI for health advice. Your privacy is ...

  6. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.

  7. Personal health record - Wikipedia

    en.wikipedia.org/wiki/Personal_health_record

    A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.

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