A medical record refers to a comprehensive compilation of healthcare-related information and data pertaining to an individual patient. It serves as a detailed documentation of a person's medical history, diagnoses, treatments, surgeries, medications, allergies, immunizations, laboratory results, and any other relevant information related to their health and healthcare interactions.
Typically, medical records are maintained and managed by healthcare professionals, such as doctors, nurses, and medical administrators, to ensure accurate and complete records of patients' health-related information are available. It is an essential tool in providing continuity of care and facilitating effective communication among healthcare providers.
A medical record contains both subjective and objective information. This may encompass a patient's symptoms, complaints, and medical history as narrated by the patient (subjective), as well as test results, imaging reports, physical examination findings, and treatment plans prepared by healthcare providers (objective). It acts as a key reference for healthcare professionals to monitor and guide patient care over time, aiding in diagnosis, treatment decisions, and evaluating the effectiveness of treatments.
Due to the sensitive nature of the information contained within medical records, they are typically protected by strict confidentiality and privacy laws and regulations. Proper handling, storage, and access control measures are essential to maintain patient confidentiality and compliance with legal requirements.
