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Patient consent is required for sharing of personal medical information, and medical certificates should therefore not contain a diagnosis without permission from the patient. [16] A number of key principles govern the issuing of medical certificate, although there are variations in procedure between jurisdictions.
A Personal Health Application (PHA) tool contains a patient's personal data (name, date of birth and other demographic details). It also includes a patient's diagnosis or health condition and details about the various treatment/assessments delivered by health professionals during an episode of care from a health care provider .
The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.
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.
The terms EHR, electronic patient record (EPR), and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist. [6] The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations.
There are many forms of PHI, with the most common being physical storage in the form of paper-based personal health records (PHR). Other types of PHI include electronic health records, wearable technology, and mobile applications. In recent years, there has been a growing number of concerns regarding the safety and privacy of PHI.
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Front cover of a PCHR from the late 1990s. The paper based child health record as used by the UK National Health Service [1] is popularly known as the "Red Book." It is given to the parents on or just after the birth of their child, and is used by parents to record standard health details such as height and weight as well as developmental milestones such as first words and first time walking. [2]
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