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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.
Other times medical criteria are presented voluntarily by an applicant in a self-assessment, without either a doctor or access to the person's medical record. Specific health criteria or medical history are required for certain jobs. In the United States, most aviators are required to possess a valid medical certificate that certifies sound ...
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.
The new Archival Records became open to unlimited access by the general public with all requests for information to such records responded by providing a copy of the entire file. Those seeking these records were required to pay a fee, whereas the "Non-Archival Records", that is, the bulk of MPRC's holdings, are provided free of charge.
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [12] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
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