Sunday, August 5, 2012

Chart

Patient's Chart:
It is use in the hospitals or clinics... It is also called as the medical record.
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite. - wikipedia.

It is a permanent paper record of the patient's health care. This record is legal record of care.

The medical chart is a confidential document that contains detailed and comprehensive information on the individual patient and their care experience. - eNotes

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