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Medical record

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95: 706:(EPR). This documentation must happen in a timely manner and encompass each and every form of treatment the patient receives, as well as other necessary information, such as the patient's case history, diagnoses, findings, treatment results, therapies and their effects, surgical interventions and their effects, as well as informed consents. The information must include virtually everything that is of functional importance for the actual, but also for future treatment. This documentation must also include the medical report and must be archived by the attending physician for at least 10 years. The law clearly states that these records are not only memory aids for the physicians, but also should be kept for the patient and must be presented on request. 717:). It contains data such as: the name of the health insurance company, the validity period of the card, and personal information about the patient (name, date of birth, sex, address, health insurance number) as well information about the patient's insurance status and additional charges. Furthermore, it can contain medical data if agreed to by the patient. This data can include information concerning emergency care, prescriptions, an electronic medical record, and electronic physician's letters. However, due to the limited storage space (32kB), some information is deposited on servers. 543: 1020:
and criminal law. Professional secrecy applies to practitioners, psychologists, nursing, physiotherapists, occupational therapists, nursing assistants, chiropodists, and administrative personnel, as well as auxiliary hospital staff. The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel. However, the precepts of privacy must be observed in all fields of hospital life: privacy at the time of the conduct of the
863:, medical records are required for the lifetime of a patient and legally for as long as that complaint action can be brought. Generally in the UK, any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patient's death to investigate illnesses within a community (e.g., industrial or environmental disease or even deaths at the hands of doctors committing murders, as in the 966: 4937: 4122: 4967: 876: 4977: 4957: 4146: 673:
complicated by the fact that the records were in electronic form and contained information supplied by other providers. McInerney maintained that she didn't have the right to release records she herself did not author. The courts ruled otherwise. Legislation followed, codifying into law the principles of the ruling. It is that legislation which deems providers the owner of medical records, but requires that
4947: 4134: 665:, the patient owns the information contained in a medical record, but the healthcare provider owns the records themselves. The same is true for both nursing home and dental records. In cases where the provider is an employee of a clinic or hospital, it is the employer that has ownership of the records. By law, all providers must keep medical records for a period of 15 years beyond the last entry. 1037: 606:, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line (so that the initial entry remains legible) and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an 558:, and are thus subject to the laws of the country/state in which they are produced. As such, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself. 1447:
Byun, Jinyoung; Schwartz, Ann G; Lusk, Christine; Wenzlaff, Angela S; de Andrade, Mariza; Mandal, Diptasri; Gaba, Colette; Yang, Ping; You, Ming; Kupert, Elena Y; Anderson, Marshall W; Han, Younghun; Li, Yafang; Qian, David; Stilp, Adrienne; Laurie, Cathy; Nelson, Sarah; Zheng, Wenying; Hung, Rayjean
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and the lack of public trust, some countries have enacted laws requiring safeguards to be put in place to protect the security and confidentiality of medical information as it is shared electronically and to give patients some important rights to monitor their medical records and receive notification
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gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g., information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's wellbeing
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Personal medical records, including X-rays, in respect of patients treated under the NHS are held to be the property of the Secretary of State. NHS hospital medical records are stored in premises designated by the appropriate health authority. Access to a patient's medical records is governed in the
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The federal Health Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy by providing medical information handling guidelines. Not only is it bound by the Code of Ethics of its profession (in the case of doctors and nurses), but also by the legislation on data protection
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contains regulatory guidelines to protect the confidentiality of patient information for healthcare organizations acting as stewards of their medical records. Despite legal precedent for access nationwide, there is still some variance in laws depending on the province. There is also some confusion
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Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records
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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. An increasing purpose of the
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Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (i.e., information
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A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further
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issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the
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Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or
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For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to
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and physical exploration, the privacy at the time of the information to the relatives, the conversations between healthcare providers in the corridors, maintenance of adequate patient data collection in hospital nursing controls (planks, slates), telephone conversations, open intercoms etc.
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ruling in McInerney v MacDonald. In that ruling, an appeal by a physician, Dr. Elizabeth McInerney, challenging a patient's access to their own medical record was denied. The patient, Margaret MacDonald, won a court order granting her full access to her own medical record. The case was
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that went into effect in 2003. This law established standards for patient privacy in all 50 states, including the right of patients to access to their own records. HIPAA provides some protection, but does not resolve the issues involving medical records privacy.
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In Germany, a relatively new law, which has been established in 2013, strengthens the rights of patients. It states, amongst other things, the statutory duty of medical personnel to document the treatment of the patient in either hard copy or within the
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is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the
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of medical record transcription and storage has the potential to violate patient–physician confidentiality by possibly allowing unaccountable persons access to patient data. With the increase of clinical notes being shared as a result of the
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J; Gaborieau, Valerie; Mckay, James; Brennan, Paul; Caporaso, Neil E; Landi, Maria Teresa; Wu, Xifeng; McLaughlin, John R; Brhane, Yonathan; Bossé, Yohan; Pinney, Susan M; Bailey-Wilson, Joan E; Amos, Christopher I (21 September 2018).
641:. Factors complicating questions of ownership include the form and source of the information, custody of the information, contract rights, and variation in state law. There is no federal law regarding ownership of medical records. 233:
has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the
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to stimulate the conversion of paper medical records into electronic charts. While many hospitals and doctor's offices have since done this successfully, electronic health vendors' proprietary systems are sometimes incompatible.
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Patients' medical information can be shared by a number of people both within the health care industry and beyond. The Health Insurance Portability and Accessibility Act (HIPAA) is a United States federal law pertaining to
742:(HIPAA). The rules become more complicated in special situations. A 2018 study found discrepancies in how major hospitals handle record requests, with forms displaying limited information relative to phone conversations. 385:
underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.
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support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to
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history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a
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In the 1992 Canadian Supreme Court ruling in McInerney v. MacDonald gave patients the right to copy and examine all information in their medical records, while the records themselves remained the property of the
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The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment,
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The contents are generally written with other healthcare professionals in mind. This can result in confusion and hurt feelings when patients read these notes. For example, some abbreviations, such as for
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include patient information that is not medical in nature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information about
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This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor or other clinician. Information on the nature and duration of the problem will be explored.
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In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been previously drafted (such as an
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Newschaffer, Craig J.; Bush, Trudy L.; Penberthy, Lynne T. (1 June 1997). "Comorbidity measurement in elderly female breast cancer patients with administrative and medical records data".
693:'s medical records has in the past generally been described as belonging to the Secretary of State for Health and this is taken by some to mean copyright also belongs to the authorities. 77:, 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. 399:
often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the
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among providers as to the scope of the patient information they have to give access to, but the language in the supreme court ruling gives patient access rights to their entire record.
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Medical and health care providers experienced 767 security breaches resulting in the compromised confidential health information of 23,625,933 patients during the period of 2006–2012.
269:. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease state. It includes several subsets detailed below. 562: 630:, the data contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record per the 80:
The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.
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Puri, Vartika; Sachdeva, Shelly; Kaur, Parmeet (1 May 2019). "Privacy preserving publication of relational and transaction data: Survey on the anonymization of patient data".
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Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.
851:(e.g., some psychiatric assessments). Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required. 192:. For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized forms to ensure patients' privacy is maintained. 1349:"Effects of colchicine on risk of cardiovascular events and mortality among patients with gout: a cohort study using electronic medical records linked with Medicare claims" 2619: 2247:
Lye, Carolyn T.; Forman, Howard P.; Gao, Ruiyi; Daniel, Jodi G.; Hsiao, Allen L.; Mann, Marilyn K.; deBronkart, Dave; Campos, Hugo O.; Krumholz, Harlan M. (2018-10-05).
3823: 896:, the increase in sensitive terms used in the records of all patients, including minors, are increasingly shared amongst care teams making privacy more complicated. 462:
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a
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in most United States jurisdictions. Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.
2153: 87:(PHR) that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by 649:, have no laws that define ownership of medical records. Twenty-one states have laws stating that the providers are the owners of the records. Only one state, 438:, muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing. 83:
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of
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for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under the guidelines of the
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protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.
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for loss and unauthorized acquisition of health information. The United States and the EU have imposed mandatory medical data breach notifications.
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across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by
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gives patients the right to access and amend their own records, but it has no language regarding ownership of the records. Twenty-eight states and
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combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.
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Lee, Jennifer; Yang, Samuel; Holland-Hall, Cynthia; Sezgin, Emre; Gill, Manjot; Linwood, Simon; Huang, Yungui; Hoffman, Jeffrey (2022-06-10).
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ownership and copyright in these records as a rule is with the NHS Trust or Health Authority, not with any individual employee or contractor.
2199: 3614: 2033: 73:, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, 4466: 2605: 2067: 826: 1801:
Klein, Jared W.; Jackson, Sara L.; Bell, Sigall K.; Anselmo, Melissa K.; Walker, Jan; Delbanco, Tom; Elmore, Joann G. (October 2016).
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are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and
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and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists,
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from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the
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of the patient, his/her careers and trainings, and religious training. It is helpful for the physician to know what sorts of
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Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.
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The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies.
4706: 3974: 3604: 3594: 3065: 1777: 470:, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health. 424:
A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
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In general, entities in possession of medical records are required to maintain those records for a given period. In the
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Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/
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Because many consider the information in medical records to be sensitive private information covered by expectations of
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medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
3078: 2371:"Prevalence of Sensitive Terms in Clinical Notes Using Natural Language Processing Techniques: Observational Study" 1683:
Chevrier, Raphaël; Foufi, Vasiliki; Gaudet-Blavignac, Christophe; Robert, Arnaud; Lovis, Christian (31 May 2019).
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Judson, Karen, B.S.; Harrison, Carlene, Ed.D., C.M.A. (2010). "Chapter 6: Medical Records and Informed Consent".
1569:"PAX: Using Pseudonymization and Anonymization to Protect Patients' Identities and Data in the Healthcare System" 847: 184:
Electronic medical records could also be studied to quantify disease burdens – such as the number of deaths from
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In addition, an electronic health insurance card was issued in January 2014 which is applicable in Germany (
4812: 4102: 3671: 3599: 3129: 1685:"Use and Understanding of Anonymization and De-Identification in the Biomedical Literature: Scoping Review" 5006: 4456: 3994: 3848: 3716: 3609: 2111: 1096: 1061: 802: 579: 1948: 594:. It is common to also find emergency contact information located in this section of the medical chart. 4436: 4067: 3666: 3280: 2874: 330: 4865: 3589: 3558: 3352: 3001: 2989: 2690: 2685: 2586: 2574: 2351: 1626:
Tamersoy, Acar; Loukides, Grigorios; Nergiz, Mehmet Ercan; Saygin, Yucel; Malin, Bradley (May 2012).
703: 542: 230: 188:– or help identify causes of, factors of and contributors to diseases, especially when combined with 5001: 4657: 4579: 4574: 4494: 4254: 4137: 4002: 3979: 3813: 3518: 3308: 3212: 2981: 2582: 2304: 1347:
Solomon, Daniel H.; Liu, Chih-Chin; Kuo, I.-Hsin; Zak, Agnes; Kim, Seoyoung C. (1 September 2016).
1056: 843: 407:" method of documentation for each visit. Each encounter will generally contain the aspects below: 185: 35: 31: 2540: 2477:
Kierkegaard Patrick (2012). "Medical data breaches: Notification delayed is notification denied".
2249:"Assessment of US Hospital Compliance With Regulations for Patients' Requests for Medical Records" 5011: 4637: 4611: 4077: 3763: 3748: 3728: 3681: 3543: 3171: 3073: 2856: 690: 669: 210: 70: 39: 30:
This article is about the documentation of a patient's medical history. For digital records, see
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are used somewhat interchangeably to describe the systematic documentation of a single
2264: 1417: 1307: 4966: 4940: 4822: 4792: 4771: 4734: 4717: 4632: 4596: 4586: 4481: 4401: 4345: 4308: 4293: 4234: 4201: 4170: 4087: 4017: 3946: 3941: 3863: 3778: 3758: 3563: 3387: 3362: 3207: 3179: 3105: 2809: 2658: 2463: 2451: 2410: 2392: 2286: 2268: 2172:"Written Answers (Commons): SOCIAL SERVICES: Medical Records (Ownership and Storage)" 2135: 1978: 1893: 1840: 1822: 1763: 1751: 1716: 1665: 1647: 1608: 1590: 1549: 1531: 1479: 1429: 1421: 1386: 1368: 1329: 1311: 1101: 781: 1862: 1364: 1292:"Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis" 209:, are similar to the abbreviations for profanities, and taking "time out" to follow 4950: 4642: 4627: 4504: 4379: 4335: 4126: 4082: 4047: 4042: 4032: 3903: 3853: 3833: 3783: 3773: 3676: 3523: 3462: 3260: 2951: 2799: 2784: 2589:(EMR) systems, allowing easy interoperability between otherwise disparate entities. 2486: 2443: 2400: 2382: 2331: 2276: 2260: 1830: 1814: 1743: 1706: 1696: 1655: 1639: 1598: 1580: 1539: 1521: 1469: 1461: 1413: 1376: 1360: 1319: 1303: 901: 880: 806: 646: 591: 519: 503: 357: 281: 266: 2082:"Who Owns Medical Records: 50 State Comparison - Health Information & the Law" 1969:
Brodnik, Melanie S., PhD, RHIA; McCain, Mary Cole, MPA, RHIA; et al. (2009).
34:. For the New York journal published by the Washington Institute of Medicine, see 4970: 4915: 4776: 4761: 4744: 4684: 4679: 4623: 4601: 4298: 4244: 4224: 4037: 3928: 3733: 3638: 3632: 3533: 3443: 3372: 2956: 2817: 2648: 2640: 2632: 1818: 1747: 1066: 1042: 1021: 945: 411: 250: 62: 2503: 238:
out of a desire to simplify patient tracking and to allow for medical research.
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Loukides, Grigorios; Gkoulalas-Divanis, Aris; Malin, Bradley (27 April 2010).
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and their outcomes. It also includes any complications of these pregnancies.
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Ownership and keeping of patient's records varies from country to country.
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The social history is a chronicle of human interactions. It tells of the
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patient's interest by the ethics of the medical and allied professions.
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information varies with the individual medical history of the patient.
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record of what has happened to the patient since birth. It chronicles
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Fundamentals of Law for Health Informatics and Information Management
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Health and Human Services HIPAA Privacy Rule for health information.
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or eGK), but also in the other member states of the European Union (
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Privacy Rights Clearinghouse's Chronology of Data Security Breaches
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became the first intersex person in Europe to successfully sue for
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is the recording of observations of the patient. This includes the
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Individuals involved in medical research, financial or management
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Health Information Technology for Economic and Clinical Health Act
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International Journal of Environmental Research and Public Health
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Al-Zubaidie, Mishall; Zhang, Zhongwei; Zhang, Ji (January 2019).
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Falsification of a medical record by a medical professional is a
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people have historically had their medical records intentionally
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In 2009, Congress authorized and funded legislation known as the
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There is no consensus regarding medical record ownership in the
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The traditional medical record for inpatient care can include
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deal primarily with the United States and do not represent a
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in the case of intersex condition was to lie to the patient.
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performed for the patient. It may have dates of operations,
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Privacy Rights Clearinghouse - Medical Privacy Information
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The Canadian Bar Association: Getting Your Medical Records
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IEEE Transactions on Information Technology in Biomedicine
1628:"Anonymization of Longitudinal Electronic Medical Records" 1495: 1493: 91:, the American Health Information Management Association. 2592: 2578: 2549: 2368: 2126:
Canada. Supreme, Court (1992). "McInerney v. MacDonald".
1213: 523: 403:(POMR), which includes a problem list of diagnoses or a " 1892:(5th ed.). New York: McGraw-Hill Higher Education. 1883: 1881: 1879: 1446: 1403: 2431:"Progress and Politics in the Intersex Rights Movement" 1800: 1490: 1450:"Genome-wide association study of familial lung cancer" 1290:
Christopher JL Murray; et al. (12 February 2022).
590:. It also contains information regarding the patient's 123:
The information contained in the medical record allows
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to the records be granted to the patient themselves.
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A medical record folder being pulled from the records
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Health Insurance Portability and Accountability Act
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Health Insurance Portability and Accountability Act
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Health Insurance Portability and Accountability Act
478:The results of testing, such as blood tests (e.g., 2593:American Health Information Management Association 2550:American Health Information Management Association 2429: 2428:Dreger, Alice D.; Herndon, April M. (2009-04-01). 2246: 1968: 827:Personal Health Information Protection Act (PHIPA) 2352:"Government 'Breached Ex-Soldier's Human Rights'" 4993: 1733: 1346: 613: 526:tracings, outputs from medical devices (such as 3151: 2577:- a patient health summary standard based upon 2125: 1861:. Office of the Surgeon General. Archived from 1506:Proceedings of the National Academy of Sciences 3276:Participative decision-making in organizations 1887: 4178: 3470: 3137: 2613: 2427: 2064:"Patient records: The struggle for ownership" 1258:. American Medical Association. 9 March 2020. 973:The examples and perspective in this section 115:patient, who may obtain copies upon request. 38:. For the BBC Radio 4 medical programme, see 1997:: CS1 maint: multiple names: authors list ( 1912:: CS1 maint: multiple names: authors list ( 344:Various habits which impact health, such as 284:, and/or the detailed narrative of what the 2227:"§ 630f BGB - Dokumentation der Behandlung" 1928:"HITECH Act Enforcement Interim Final Rule" 656: 546:A ward clerk in the Menn Hospital, Colorado 449: 4467:Reproductive endocrinology and infertility 4185: 4171: 3477: 3463: 3144: 3130: 2620: 2606: 2566:Organizations dealing with medical records 991:, or create a new section, as appropriate. 4808:Bachelor of Medicine, Bachelor of Surgery 2436:GLQ: A Journal of Lesbian and Gay Studies 2404: 2386: 2335: 2280: 1834: 1710: 1700: 1659: 1602: 1584: 1543: 1525: 1473: 1380: 1323: 1007:Learn how and when to remove this message 696: 874: 541: 537: 506:is included in lieu of the actual film. 498:results), or specialized testing (e.g., 93: 2166: 276:The surgical history is a chronicle of 14: 4994: 3687:Nursing credentials and certifications 668:The precedent for the law is the 1992 381:Growth chart and developmental history 378:will also be included in this section. 4166: 3458: 3125: 2601: 2559:Electronic Privacy Information Center 2317: 2121: 2119: 1796: 1794: 680: 621: 389: 374:is included. Any blood tests proving 215:a disciplinary technique for children 4946: 4707:Physical medicine and rehabilitation 4133: 3975:Nursing Interventions Classification 2324:Canadian Medical Association Journal 2154:"CMPA: Who Owns the Medical Record?" 1890:Law & Ethics for Medical Careers 1689:Journal of Medical Internet Research 959: 766:), and patients with incapacitating 509: 4956: 4145: 3007:Upper limb neurological examination 2096:"CMPA: Electronic Records Handbook" 554:that can be used as evidence via a 24: 4843:Medical Scientist Training Program 3296:Health information on the Internet 2479:Computer Law & Security Review 2116: 1791: 787:Research, auditing, and evaluation 674: 244: 25: 5023: 2534: 2265:10.1001/jamanetworkopen.2018.3014 2205:. Mersey Care NHS Trust. Nov 2016 1142:. CMS. April 2011. Archived from 833: 586:as well as workplace and type of 457: 305:Medications and medical allergies 4975: 4965: 4955: 4945: 4936: 4935: 4144: 4132: 4121: 4120: 1807:The American Journal of Medicine 1406:Journal of Clinical Epidemiology 1353:Annals of the Rheumatic Diseases 1035: 964: 930: 725: 720: 220: 4976: 3985:Nursing Outcomes Classification 3980:Nursing Minimum Data Set (NMDS) 3652:Associate of Science in Nursing 3429:Open-source healthcare software 3304:Health information on Knowledge 3028:Ballard Maturational Assessment 2888:Peripheral vascular examination 2520: 2508: 2497: 2470: 2421: 2362: 2344: 2311: 2297: 2240: 2219: 2192: 2160: 2146: 2105: 2088: 2074: 2056: 2042: 2026: 2005: 1962: 1951:. undark.org. 24 September 2018 1941: 1920: 1851: 1770: 1727: 1676: 1619: 1560: 1440: 1397: 1365:10.1136/annrheumdis-2015-207984 1193:"National Institute for Health" 848:Freedom of Information Act 2000 569: 473: 401:problem-oriented medical record 190:genome-wide association studies 4833:Doctor of Osteopathic Medicine 4267:Oral and maxillofacial surgery 3657:Bachelor of Science in Nursing 2654:History of the present illness 1340: 1283: 1262: 1248: 1227: 1206: 1185: 1160: 1129: 854: 715:European Health Insurance Card 711:Elektronische Gesundheitskarte 420:History of the present illness 13: 1: 3879:Psychiatric and mental health 2995:Mini–mental state examination 2906:Ankle–brachial pressure index 1418:10.1016/S0895-4356(97)00050-4 1308:10.1016/S0140-6736(21)02724-0 1123: 749:When a patient does not have 614:Ownership of patient's record 597: 4813:Bachelor of Medical Sciences 4580:Neurosurgical anesthesiology 4192: 3672:Master of Science in Nursing 1819:10.1016/j.amjmed.2016.05.015 1748:10.1016/j.cosrev.2019.02.001 1235:"Health Information Privacy" 1168:"Frequently Asked Questions" 935:Given the series of medical 226:are often archived offsite. 7: 3484: 3246:Doctor–patient relationship 3153:Telemedicine and telehealth 1859:"My Family Health Portrait" 1170:. MyPHR.com. Archived from 1097:Physician-patient privilege 1062:Hospital information system 1028: 987:, discuss the issue on the 910:intersex medical procedures 803:United States Supreme Court 195: 10: 5028: 3667:Doctor of Nursing Practice 3281:Patient Activation Measure 2491:10.1016/j.clsr.2012.01.003 2015:. Aspe.hhs.gov. 1996-08-21 1930:. Hhs.gov. 28 October 2009 955: 500:pulmonary function testing 231:electronic medical records 213:might be misunderstood as 211:a surgical safety protocol 29: 4931: 4853: 4791: 4552: 4480: 4435: 4344: 4215: 4200: 4116: 3993: 3960: 3927: 3824:Women's Health Care Nurse 3715: 3631: 3582: 3559:Clinical nurse specialist 3551: 3542: 3501: 3492: 3421: 3353:Remote patient monitoring 3327: 3294: 3231: 3188: 3159: 3096: 3064: 3036: 3015: 3002:Cranial nerve examination 2980: 2944: 2916: 2873: 2855: 2808: 2775: 2741: 2732: 2639: 2587:Electronic Medical Record 2575:Continuity of Care Record 2448:10.1215/10642684-2008-134 1644:10.1109/TITB.2012.2185850 1137:"Personal Health Records" 870: 815: 704:electronic patient record 4767:Transplantation medicine 4658:Clinical neurophysiology 4575:Obstetric anesthesiology 4495:Interventional radiology 4255:Digestive system surgery 4003:International Nurses Day 3519:Licensed practical nurse 3309:Online patient education 3213:Electronic health record 2541:Personal Medical Records 2375:JMIR Medical Informatics 1778:"A Sample Health Record" 1272:. McKinley Health Center 1057:Electronic health record 657:Canadian law and customs 450:Orders and prescriptions 186:antimicrobial resistance 71:healthcare professionals 36:Medical Record (journal) 32:electronic health record 4638:Intensive care medicine 4612:Mass gathering medicine 4457:Maternal–fetal medicine 3682:Nurse Licensure Compact 3074:Athletic heart syndrome 1736:Computer Science Review 1527:10.1073/pnas.0911686107 1216:. Ahima.org. 2012-03-22 179:Personal health records 118: 85:personal health records 40:Case Notes (radio show) 4230:Cardiothoracic surgery 3434:Patient opinion leader 3286:Shared decision-making 3223:Personal health record 3111:Differential diagnosis 3046:Well-woman examination 2555:Medical Record Privacy 1586:10.3390/ijerph16091490 894:21st Century Cures Act 884: 697:German law and customs 670:Canadian Supreme Court 547: 468:respiratory therapists 99: 4881:Personalized medicine 4740:Reproductive medicine 4665:Occupational medicine 4619:Evolutionary medicine 3914:Travel health nursing 3514:Clinical nurse leader 3266:Knowledge translation 3233:Patient participation 1466:10.1093/carcin/bgy080 1082:Patient record access 878: 797:Risk of death or harm 545: 538:Administrative issues 125:health care providers 97: 4901:Traditional medicine 4861:Alternative medicine 4728:Addiction psychiatry 4542:Transfusion medicine 4537:Medical microbiology 4452:Gynecologic oncology 4304:Reproductive surgery 3739:Correctional nursing 3439:Research participant 3079:Sudden cardiac death 2962:Shoulder examination 2901:Abdominojugular test 2734:Physical examination 2681:Past medical history 2318:Grant, D.A. (1998). 2170:(30 November 1976). 2128:Dominion Law Reports 1092:Physical examination 985:improve this section 844:Data Protection Acts 663:Canadian federal law 608:electronic signature 556:subpoena duces tecum 550:Medical records are 516:intensive care units 486:examinations (e.g., 480:complete blood count 432:physical examination 427:Physical examination 367:Immunization history 298:history lists prior 4923:History of medicine 4906:Veterinary medicine 4713:Preventive medicine 4565:Adolescent medicine 4407:Infectious diseases 4073:Republic of Ireland 3849:Occupational health 3839:Nursing informatics 3615:Psych/mental health 3160:Background concepts 3098:Assessment and plan 2883:Cardiac examination 2828:Swinging light test 2696:Psychiatric history 2629:Medical examination 2358:. October 20, 2004. 1518:2010PNAS..107.7898L 918:medical malpractice 902:falsified/concealed 823:healthcare provider 689:, ownership of the 441:Assessment and plan 207:shortness of breath 157:postoperative notes 5007:Health informatics 4871:Molecular oncology 4828:Doctor of Medicine 4818:Master of Medicine 4735:Radiation oncology 4607:Emergency medicine 4560:Addiction medicine 4527:Clinical chemistry 4522:Clinical pathology 4314:Transplant surgery 4272:Orthopedic surgery 4250:Colorectal surgery 3937:Nursing assessment 3799:Legal consultation 3662:Diploma in Nursing 3647:Nightingale Pledge 3574:Nurse practitioner 3413:Telerehabilitation 3167:Health informatics 3056:Breast examination 2931:Rectal examination 2865:Respiratory sounds 2664:Nursing assessment 1302:(10325): 629–655. 914:Christiane Völling 885: 681:UK law and customs 622:US law and customs 548: 395:consultation by a 390:Medical encounters 362:sexual orientation 261:, major and minor 149:preoperative notes 100: 4989: 4988: 4823:Master of Surgery 4787: 4786: 4772:Tropical medicine 4718:Prison healthcare 4633:Hospital medicine 4597:Disaster medicine 4587:Aviation medicine 4402:Hospital medicine 4309:Surgical oncology 4294:Pediatric surgery 4288: 4235:Endocrine surgery 4160: 4159: 3947:Nursing care plan 3942:Nursing diagnosis 3627: 3626: 3623: 3622: 3595:Adult-gerontology 3583:NPs by population 3564:Nurse anesthetist 3544:Advanced practice 3452: 3451: 3388:Teleophthalmology 3378:Telemental health 3363:Tele-epidemiology 3208:De-identification 3180:Telecommunication 3119: 3118: 3106:Medical diagnosis 3092: 3091: 2967:Elbow examination 2253:JAMA Network Open 1984:978-1-58426-173-5 1813:(10): 1018–1021. 1512:(17): 7898–7903. 1270:"Medical Records" 1102:Labour inspection 1017: 1016: 1009: 782:advance directive 777:Medical emergency 762:, minors (unless 510:Other information 291:Obstetric history 282:operative reports 16:(Redirected from 5019: 4979: 4978: 4969: 4959: 4958: 4949: 4948: 4939: 4938: 4643:Medical genetics 4628:General practice 4505:Nuclear medicine 4380:Gastroenterology 4336:Vascular surgery 4286: 4213: 4212: 4187: 4180: 4173: 4164: 4163: 4148: 4147: 4136: 4135: 4124: 4123: 3814:Medical-surgical 3717:Specialties and 3677:Board of nursing 3549: 3548: 3524:Registered nurse 3499: 3498: 3479: 3472: 3465: 3456: 3455: 3261:Health education 3146: 3139: 3132: 3123: 3122: 2952:Knee examination 2800:Respiratory rate 2739: 2738: 2622: 2615: 2608: 2599: 2598: 2529: 2524: 2518: 2512: 2506: 2501: 2495: 2494: 2474: 2468: 2467: 2433: 2425: 2419: 2418: 2408: 2390: 2366: 2360: 2359: 2348: 2342: 2341: 2339: 2315: 2309: 2308: 2301: 2295: 2294: 2284: 2244: 2238: 2237: 2235: 2234: 2223: 2217: 2216: 2211: 2210: 2204: 2196: 2190: 2189: 2164: 2158: 2157: 2150: 2144: 2143: 2123: 2114: 2109: 2103: 2102: 2100: 2092: 2086: 2085: 2078: 2072: 2071: 2066:. Archived from 2060: 2054: 2053: 2046: 2040: 2039: 2030: 2024: 2023: 2021: 2020: 2009: 2003: 2002: 1996: 1988: 1966: 1960: 1959: 1957: 1956: 1945: 1939: 1938: 1936: 1935: 1924: 1918: 1917: 1911: 1903: 1885: 1874: 1873: 1871: 1870: 1855: 1849: 1848: 1838: 1798: 1789: 1788: 1786: 1785: 1774: 1768: 1767: 1731: 1725: 1724: 1714: 1704: 1680: 1674: 1673: 1663: 1623: 1617: 1616: 1606: 1588: 1564: 1558: 1557: 1547: 1529: 1497: 1488: 1487: 1477: 1460:(9): 1135–1140. 1444: 1438: 1437: 1401: 1395: 1394: 1384: 1359:(9): 1674–1679. 1344: 1338: 1337: 1327: 1287: 1281: 1280: 1278: 1277: 1266: 1260: 1259: 1252: 1246: 1245: 1243: 1242: 1231: 1225: 1224: 1222: 1221: 1210: 1204: 1203: 1201: 1200: 1189: 1183: 1182: 1180: 1179: 1164: 1158: 1157: 1155: 1154: 1148: 1141: 1133: 1045: 1040: 1039: 1038: 1012: 1005: 1001: 998: 992: 968: 967: 960: 881:standard of care 807:Jaffe v. Redmond 647:Washington, D.C. 592:health insurance 520:informed consent 273:Surgical history 267:growth landmarks 169:postpartum notes 137:on-service notes 21: 5027: 5026: 5022: 5021: 5020: 5018: 5017: 5016: 5002:Medical records 4992: 4991: 4990: 4985: 4927: 4916:Chief physician 4849: 4794: 4783: 4777:Travel medicine 4762:Sports medicine 4745:Sexual medicine 4685:Palliative care 4680:Pain management 4624:Family medicine 4602:Diving medicine 4548: 4476: 4438: 4431: 4347: 4340: 4299:Plastic surgery 4245:General surgery 4225:Cardiac surgery 4206: 4204: 4196: 4191: 4161: 4156: 4112: 3989: 3962: 3961:Classification 3956: 3929:Nursing process 3923: 3764:Faith community 3729:Ambulatory care 3720: 3718: 3711: 3637: 3635: 3619: 3578: 3538: 3534:Nurse scientist 3494: 3488: 3483: 3453: 3448: 3444:Virtual patient 3417: 3373:Teledermatology 3323: 3290: 3227: 3184: 3155: 3150: 3120: 3115: 3088: 3060: 3032: 3011: 2976: 2957:Hip examination 2945:Musculoskeletal 2940: 2912: 2869: 2851: 2818:Eye examination 2804: 2771: 2728: 2649:Chief complaint 2641:Medical history 2635: 2626: 2568: 2537: 2532: 2525: 2521: 2513: 2509: 2502: 2498: 2475: 2471: 2426: 2422: 2367: 2363: 2350: 2349: 2345: 2316: 2312: 2303: 2302: 2298: 2245: 2241: 2232: 2230: 2225: 2224: 2220: 2208: 2206: 2202: 2198: 2197: 2193: 2165: 2161: 2152: 2151: 2147: 2124: 2117: 2110: 2106: 2098: 2094: 2093: 2089: 2080: 2079: 2075: 2062: 2061: 2057: 2048: 2047: 2043: 2032: 2031: 2027: 2018: 2016: 2011: 2010: 2006: 1990: 1989: 1985: 1977:. p. 239. 1967: 1963: 1954: 1952: 1947: 1946: 1942: 1933: 1931: 1926: 1925: 1921: 1905: 1904: 1900: 1886: 1877: 1868: 1866: 1857: 1856: 1852: 1799: 1792: 1783: 1781: 1776: 1775: 1771: 1732: 1728: 1681: 1677: 1624: 1620: 1565: 1561: 1498: 1491: 1445: 1441: 1402: 1398: 1345: 1341: 1288: 1284: 1275: 1273: 1268: 1267: 1263: 1254: 1253: 1249: 1240: 1238: 1233: 1232: 1228: 1219: 1217: 1212: 1211: 1207: 1198: 1196: 1191: 1190: 1186: 1177: 1175: 1166: 1165: 1161: 1152: 1150: 1146: 1139: 1135: 1134: 1130: 1126: 1121: 1067:Medical history 1043:Medicine portal 1041: 1036: 1034: 1031: 1013: 1002: 996: 993: 982: 969: 965: 958: 946:medical privacy 933: 873: 857: 836: 818: 728: 723: 699: 683: 659: 624: 616: 600: 572: 552:legal documents 540: 512: 476: 460: 452: 412:Chief complaint 392: 370:The history of 251:medical history 247: 245:Medical history 223: 198: 173:discharge notes 161:procedure notes 153:operative notes 133:admission notes 121: 63:medical history 43: 28: 23: 22: 15: 12: 11: 5: 5025: 5015: 5014: 5012:Public records 5009: 5004: 4987: 4986: 4984: 4983: 4973: 4963: 4953: 4943: 4932: 4929: 4928: 4926: 4925: 4920: 4919: 4918: 4908: 4903: 4898: 4893: 4888: 4883: 4878: 4873: 4868: 4863: 4857: 4855: 4854:Related topics 4851: 4850: 4848: 4847: 4846: 4845: 4835: 4830: 4825: 4820: 4815: 4810: 4805: 4803:Medical school 4799: 4797: 4789: 4788: 4785: 4784: 4782: 4781: 4780: 4779: 4769: 4764: 4759: 4757:Sleep medicine 4754: 4753: 4752: 4742: 4737: 4732: 4731: 4730: 4720: 4715: 4710: 4704: 4699: 4698: 4697: 4687: 4682: 4677: 4672: 4667: 4662: 4661: 4660: 4650: 4645: 4640: 4635: 4630: 4621: 4616: 4615: 4614: 4604: 4599: 4594: 4589: 4584: 4583: 4582: 4577: 4570:Anesthesiology 4567: 4562: 4556: 4554: 4550: 4549: 4547: 4546: 4545: 4544: 4539: 4534: 4529: 4524: 4519: 4509: 4508: 4507: 4502: 4500:Neuroradiology 4497: 4486: 4484: 4478: 4477: 4475: 4474: 4469: 4464: 4459: 4454: 4449: 4443: 4441: 4437:Obstetrics and 4433: 4432: 4430: 4429: 4424: 4419: 4414: 4409: 4404: 4399: 4394: 4389: 4388: 4387: 4377: 4372: 4367: 4362: 4352: 4350: 4342: 4341: 4339: 4338: 4333: 4332: 4331: 4321: 4319:Trauma surgery 4316: 4311: 4306: 4301: 4296: 4291: 4290: 4289: 4282:Otolaryngology 4279: 4274: 4269: 4264: 4259: 4258: 4257: 4252: 4242: 4237: 4232: 4227: 4221: 4219: 4210: 4208:subspecialties 4198: 4197: 4190: 4189: 4182: 4175: 4167: 4158: 4157: 4155: 4154: 4142: 4130: 4117: 4114: 4113: 4111: 4110: 4100: 4093:United Kingdom 4090: 4085: 4080: 4075: 4070: 4065: 4060: 4050: 4045: 4040: 4035: 4030: 4025: 4020: 4015: 4005: 3999: 3997: 3991: 3990: 3988: 3987: 3982: 3977: 3972: 3966: 3964: 3958: 3957: 3955: 3954: 3952:Nursing theory 3949: 3944: 3939: 3933: 3931: 3925: 3924: 3922: 3921: 3916: 3911: 3906: 3901: 3896: 3891: 3886: 3881: 3876: 3871: 3869:Perianesthesia 3866: 3861: 3856: 3851: 3846: 3841: 3836: 3831: 3826: 3821: 3816: 3811: 3806: 3801: 3796: 3791: 3786: 3781: 3776: 3771: 3766: 3761: 3756: 3751: 3746: 3741: 3736: 3731: 3725: 3723: 3713: 3712: 3710: 3709: 3704: 3699: 3697:Nurse registry 3694: 3692:Nursing school 3689: 3684: 3679: 3674: 3669: 3664: 3659: 3654: 3649: 3643: 3641: 3629: 3628: 3625: 3624: 3621: 3620: 3618: 3617: 3612: 3607: 3605:Women's health 3602: 3597: 3592: 3586: 3584: 3580: 3579: 3577: 3576: 3571: 3566: 3561: 3555: 3553: 3546: 3540: 3539: 3537: 3536: 3531: 3529:Graduate nurse 3526: 3521: 3516: 3511: 3505: 3503: 3496: 3490: 3489: 3482: 3481: 3474: 3467: 3459: 3450: 3449: 3447: 3446: 3441: 3436: 3431: 3425: 3423: 3419: 3418: 3416: 3415: 3410: 3405: 3403:Telepsychiatry 3400: 3395: 3390: 3385: 3380: 3375: 3370: 3365: 3360: 3358:Tele-audiology 3355: 3350: 3348:Remote therapy 3345: 3343:Remote surgery 3340: 3334: 3332: 3330:subspecialties 3325: 3324: 3322: 3321: 3319:PubMed Central 3316: 3311: 3306: 3300: 3298: 3292: 3291: 3289: 3288: 3283: 3278: 3273: 3268: 3263: 3258: 3253: 3248: 3243: 3237: 3235: 3229: 3228: 3226: 3225: 3220: 3215: 3210: 3205: 3200: 3198:Admission note 3194: 3192: 3190:Medical record 3186: 3185: 3183: 3182: 3177: 3169: 3163: 3161: 3157: 3156: 3149: 3148: 3141: 3134: 3126: 3117: 3116: 3114: 3113: 3108: 3102: 3100: 3094: 3093: 3090: 3089: 3087: 3086: 3081: 3076: 3070: 3068: 3062: 3061: 3059: 3058: 3053: 3048: 3042: 3040: 3034: 3033: 3031: 3030: 3025: 3019: 3017: 3013: 3012: 3010: 3009: 3004: 2999: 2998: 2997: 2986: 2984: 2978: 2977: 2975: 2974: 2969: 2964: 2959: 2954: 2948: 2946: 2942: 2941: 2939: 2938: 2933: 2928: 2922: 2920: 2914: 2913: 2911: 2910: 2909: 2908: 2903: 2895: 2890: 2885: 2879: 2877: 2875:Cardiovascular 2871: 2870: 2868: 2867: 2861: 2859: 2853: 2852: 2850: 2849: 2848: 2847: 2842: 2832: 2831: 2830: 2825: 2823:Ophthalmoscopy 2814: 2812: 2806: 2805: 2803: 2802: 2797: 2795:Blood pressure 2792: 2787: 2781: 2779: 2773: 2772: 2770: 2769: 2764: 2759: 2754: 2748: 2746: 2736: 2730: 2729: 2727: 2726: 2725: 2724: 2721: 2716: 2711: 2703: 2701:Progress notes 2698: 2693: 2691:Social history 2688: 2686:Family history 2683: 2678: 2677: 2676: 2666: 2661: 2659:Systems review 2656: 2651: 2645: 2643: 2637: 2636: 2633:history taking 2625: 2624: 2617: 2610: 2602: 2596: 2595: 2590: 2567: 2564: 2563: 2562: 2552: 2547: 2536: 2535:External links 2533: 2531: 2530: 2519: 2507: 2496: 2485:(2): 163–183. 2469: 2442:(2): 199–224. 2420: 2361: 2343: 2310: 2296: 2259:(6): e183014. 2239: 2218: 2191: 2159: 2145: 2115: 2104: 2087: 2073: 2070:on 2015-12-10. 2055: 2041: 2025: 2013:"P.L. 104-191" 2004: 1983: 1961: 1940: 1919: 1898: 1875: 1850: 1790: 1769: 1726: 1675: 1638:(3): 413–423. 1618: 1559: 1489: 1454:Carcinogenesis 1439: 1412:(6): 725–733. 1396: 1339: 1282: 1261: 1247: 1226: 1205: 1184: 1159: 1127: 1125: 1122: 1120: 1119: 1117:Pharmaceutical 1114: 1109: 1104: 1099: 1094: 1089: 1084: 1079: 1074: 1069: 1064: 1059: 1054: 1048: 1047: 1046: 1030: 1027: 1015: 1014: 979:of the subject 977:worldwide view 972: 970: 963: 957: 954: 932: 929: 872: 869: 865:Harold Shipman 861:United Kingdom 856: 853: 846:and later the 840:United Kingdom 835: 834:United Kingdom 832: 817: 814: 813: 812: 798: 795: 788: 785: 778: 775: 755:legal guardian 747: 727: 724: 722: 719: 698: 695: 687:United Kingdom 682: 679: 658: 655: 623: 620: 615: 612: 599: 596: 571: 568: 539: 536: 511: 508: 475: 472: 459: 458:Progress notes 456: 451: 448: 447: 446: 442: 439: 428: 425: 422: 417: 414: 391: 388: 387: 386: 382: 379: 368: 365: 342: 339: 327: 326:Social history 324: 321:pedigree chart 312: 311:Family history 309: 306: 303: 292: 289: 274: 246: 243: 229:The advent of 222: 219: 197: 194: 165:delivery notes 141:progress notes 120: 117: 47:medical record 26: 18:Patient record 9: 6: 4: 3: 2: 5024: 5013: 5010: 5008: 5005: 5003: 5000: 4999: 4997: 4982: 4974: 4972: 4968: 4964: 4962: 4954: 4952: 4944: 4942: 4934: 4933: 4930: 4924: 4921: 4917: 4914: 4913: 4912: 4909: 4907: 4904: 4902: 4899: 4897: 4894: 4892: 4889: 4887: 4886:Public health 4884: 4882: 4879: 4877: 4874: 4872: 4869: 4867: 4866:Allied health 4864: 4862: 4859: 4858: 4856: 4852: 4844: 4841: 4840: 4839: 4836: 4834: 4831: 4829: 4826: 4824: 4821: 4819: 4816: 4814: 4811: 4809: 4806: 4804: 4801: 4800: 4798: 4796: 4790: 4778: 4775: 4774: 4773: 4770: 4768: 4765: 4763: 4760: 4758: 4755: 4751: 4748: 4747: 4746: 4743: 4741: 4738: 4736: 4733: 4729: 4726: 4725: 4724: 4721: 4719: 4716: 4714: 4711: 4708: 4705: 4703: 4700: 4696: 4693: 4692: 4691: 4688: 4686: 4683: 4681: 4678: 4676: 4675:Oral medicine 4673: 4671: 4670:Ophthalmology 4668: 4666: 4663: 4659: 4656: 4655: 4654: 4651: 4649: 4646: 4644: 4641: 4639: 4636: 4634: 4631: 4629: 4625: 4622: 4620: 4617: 4613: 4610: 4609: 4608: 4605: 4603: 4600: 4598: 4595: 4593: 4590: 4588: 4585: 4581: 4578: 4576: 4573: 4572: 4571: 4568: 4566: 4563: 4561: 4558: 4557: 4555: 4551: 4543: 4540: 4538: 4535: 4533: 4532:Cytopathology 4530: 4528: 4525: 4523: 4520: 4518: 4515: 4514: 4513: 4510: 4506: 4503: 4501: 4498: 4496: 4493: 4492: 4491: 4488: 4487: 4485: 4483: 4479: 4473: 4472:Urogynecology 4470: 4468: 4465: 4463: 4460: 4458: 4455: 4453: 4450: 4448: 4445: 4444: 4442: 4440: 4434: 4428: 4425: 4423: 4420: 4418: 4415: 4413: 4410: 4408: 4405: 4403: 4400: 4398: 4395: 4393: 4390: 4386: 4383: 4382: 4381: 4378: 4376: 4375:Endocrinology 4373: 4371: 4368: 4366: 4363: 4361: 4357: 4354: 4353: 4351: 4349: 4343: 4337: 4334: 4330: 4327: 4326: 4325: 4322: 4320: 4317: 4315: 4312: 4310: 4307: 4305: 4302: 4300: 4297: 4295: 4292: 4285: 4284: 4283: 4280: 4278: 4275: 4273: 4270: 4268: 4265: 4263: 4260: 4256: 4253: 4251: 4248: 4247: 4246: 4243: 4241: 4238: 4236: 4233: 4231: 4228: 4226: 4223: 4222: 4220: 4218: 4214: 4211: 4209: 4203: 4199: 4195: 4188: 4183: 4181: 4176: 4174: 4169: 4168: 4165: 4153: 4152: 4143: 4141: 4140: 4131: 4129: 4128: 4119: 4118: 4115: 4108: 4104: 4103:United States 4101: 4098: 4094: 4091: 4089: 4086: 4084: 4081: 4079: 4076: 4074: 4071: 4069: 4066: 4064: 4061: 4058: 4054: 4051: 4049: 4046: 4044: 4041: 4039: 4036: 4034: 4031: 4029: 4026: 4024: 4021: 4019: 4016: 4013: 4009: 4006: 4004: 4001: 4000: 3998: 3996: 3992: 3986: 3983: 3981: 3978: 3976: 3973: 3971: 3968: 3967: 3965: 3959: 3953: 3950: 3948: 3945: 3943: 3940: 3938: 3935: 3934: 3932: 3930: 3926: 3920: 3917: 3915: 3912: 3910: 3907: 3905: 3902: 3900: 3897: 3895: 3892: 3890: 3889:Public health 3887: 3885: 3882: 3880: 3877: 3875: 3874:Perioperative 3872: 3870: 3867: 3865: 3862: 3860: 3857: 3855: 3852: 3850: 3847: 3845: 3842: 3840: 3837: 3835: 3832: 3830: 3827: 3825: 3822: 3820: 3817: 3815: 3812: 3810: 3807: 3805: 3802: 3800: 3797: 3795: 3792: 3790: 3787: 3785: 3782: 3780: 3777: 3775: 3772: 3770: 3767: 3765: 3762: 3760: 3757: 3755: 3752: 3750: 3747: 3745: 3744:Critical care 3742: 3740: 3737: 3735: 3732: 3730: 3727: 3726: 3724: 3722: 3714: 3708: 3705: 3703: 3700: 3698: 3695: 3693: 3690: 3688: 3685: 3683: 3680: 3678: 3675: 3673: 3670: 3668: 3665: 3663: 3660: 3658: 3655: 3653: 3650: 3648: 3645: 3644: 3642: 3640: 3634: 3630: 3616: 3613: 3611: 3608: 3606: 3603: 3601: 3598: 3596: 3593: 3591: 3588: 3587: 3585: 3581: 3575: 3572: 3570: 3569:Nurse midwife 3567: 3565: 3562: 3560: 3557: 3556: 3554: 3550: 3547: 3545: 3541: 3535: 3532: 3530: 3527: 3525: 3522: 3520: 3517: 3515: 3512: 3510: 3509:Student nurse 3507: 3506: 3504: 3500: 3497: 3491: 3487: 3480: 3475: 3473: 3468: 3466: 3461: 3460: 3457: 3445: 3442: 3440: 3437: 3435: 3432: 3430: 3427: 3426: 3424: 3422:Roles to play 3420: 3414: 3411: 3409: 3408:Teleradiology 3406: 3404: 3401: 3399: 3396: 3394: 3393:Telepathology 3391: 3389: 3386: 3384: 3381: 3379: 3376: 3374: 3371: 3369: 3368:Teledentistry 3366: 3364: 3361: 3359: 3356: 3354: 3351: 3349: 3346: 3344: 3341: 3339: 3336: 3335: 3333: 3331: 3328:Telemedicine 3326: 3320: 3317: 3315: 3312: 3310: 3307: 3305: 3302: 3301: 3299: 3297: 3293: 3287: 3284: 3282: 3279: 3277: 3274: 3272: 3269: 3267: 3264: 3262: 3259: 3257: 3254: 3252: 3249: 3247: 3244: 3242: 3241:Decision aids 3239: 3238: 3236: 3234: 3230: 3224: 3221: 3219: 3216: 3214: 3211: 3209: 3206: 3204: 3201: 3199: 3196: 3195: 3193: 3191: 3187: 3181: 3178: 3176: 3174: 3170: 3168: 3165: 3164: 3162: 3158: 3154: 3147: 3142: 3140: 3135: 3133: 3128: 3127: 3124: 3112: 3109: 3107: 3104: 3103: 3101: 3099: 3095: 3085: 3082: 3080: 3077: 3075: 3072: 3071: 3069: 3067: 3063: 3057: 3054: 3052: 3049: 3047: 3044: 3043: 3041: 3039: 3038:Gynecological 3035: 3029: 3026: 3024: 3021: 3020: 3018: 3014: 3008: 3005: 3003: 3000: 2996: 2993: 2992: 2991: 2990:Mental status 2988: 2987: 2985: 2983: 2979: 2973: 2970: 2968: 2965: 2963: 2960: 2958: 2955: 2953: 2950: 2949: 2947: 2943: 2937: 2934: 2932: 2929: 2927: 2924: 2923: 2921: 2919: 2915: 2907: 2904: 2902: 2899: 2898: 2896: 2894: 2891: 2889: 2886: 2884: 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Nlm.nih.gov 1779: 1773: 1765: 1761: 1757: 1753: 1749: 1745: 1741: 1737: 1730: 1722: 1718: 1713: 1708: 1703: 1702:10.2196/13484 1698: 1695:(5): e13484. 1694: 1690: 1686: 1679: 1671: 1667: 1662: 1657: 1653: 1649: 1645: 1641: 1637: 1633: 1629: 1622: 1614: 1610: 1605: 1600: 1596: 1592: 1587: 1582: 1578: 1574: 1570: 1563: 1555: 1551: 1546: 1541: 1537: 1533: 1528: 1523: 1519: 1515: 1511: 1507: 1503: 1496: 1494: 1485: 1481: 1476: 1471: 1467: 1463: 1459: 1455: 1451: 1443: 1435: 1431: 1427: 1423: 1419: 1415: 1411: 1407: 1400: 1392: 1388: 1383: 1378: 1374: 1370: 1366: 1362: 1358: 1354: 1350: 1343: 1335: 1331: 1326: 1321: 1317: 1313: 1309: 1305: 1301: 1297: 1293: 1286: 1271: 1265: 1257: 1251: 1236: 1230: 1215: 1209: 1194: 1188: 1174:on 2012-04-11 1173: 1169: 1163: 1149:on 2012-03-05 1145: 1138: 1132: 1128: 1118: 1115: 1113: 1110: 1108: 1105: 1103: 1100: 1098: 1095: 1093: 1090: 1088: 1087:Right to know 1085: 1083: 1080: 1078: 1075: 1073: 1070: 1068: 1065: 1063: 1060: 1058: 1055: 1053: 1050: 1049: 1044: 1033: 1026: 1023: 1011: 1008: 1000: 997:December 2012 990: 986: 980: 978: 971: 962: 961: 953: 950: 947: 941: 938: 937:data breaches 931:Data breaches 928: 926: 921: 919: 915: 911: 907: 903: 899: 895: 890: 882: 877: 868: 866: 862: 852: 849: 845: 841: 831: 828: 824: 810: 808: 804: 799: 796: 793: 789: 786: 783: 779: 776: 773: 769: 765: 761: 756: 752: 748: 745: 744: 743: 741: 737: 733: 732:United States 726:United States 721:Accessibility 718: 716: 712: 707: 705: 694: 692: 688: 678: 676: 671: 666: 664: 654: 652: 651:New Hampshire 648: 644: 640: 639:United States 635: 633: 629: 628:United States 619: 611: 609: 605: 604:United States 595: 593: 589: 585: 581: 576: 567: 564: 559: 557: 553: 544: 535: 533: 529: 525: 521: 517: 507: 505: 501: 497: 493: 489: 485: 481: 471: 469: 465: 455: 443: 440: 437: 433: 429: 426: 423: 421: 418: 415: 413: 410: 409: 408: 406: 402: 398: 383: 380: 377: 373: 369: 366: 363: 359: 355: 351: 347: 343: 340: 336: 332: 331:relationships 328: 325: 322: 317: 313: 310: 307: 304: 301: 297: 293: 290: 287: 283: 279: 275: 272: 271: 270: 268: 265:, as well as 264: 260: 256: 252: 242: 239: 237: 232: 227: 221:Media applied 218: 216: 212: 208: 202: 193: 191: 187: 182: 180: 176: 174: 170: 166: 162: 158: 154: 150: 146: 142: 138: 134: 129: 126: 116: 113: 109: 105: 96: 92: 90: 86: 81: 78: 76: 72: 68: 64: 60: 56: 55:medical chart 52: 51:health record 48: 41: 37: 33: 19: 4891:Rural health 4876:Nanomedicine 4427:Rheumatology 4358: / 4277:Hand surgery 4262:Neurosurgery 4149: 4138: 4125: 4078:South Africa 3884:Private duty 3552:APNs by role 3398:Telepharmacy 3189: 3172: 2982:Neurological 2936:Bowel sounds 2893:Heart sounds 2757:Auscultation 2522: 2510: 2499: 2482: 2478: 2472: 2439: 2435: 2423: 2378: 2374: 2364: 2356:The Guardian 2355: 2346: 2327: 2323: 2313: 2299: 2256: 2252: 2242: 2231:. Retrieved 2229:. dejure.org 2221: 2213: 2207:. Retrieved 2194: 2185: 2181: 2175: 2162: 2148: 2131: 2127: 2107: 2090: 2076: 2068:the original 2058: 2044: 2028: 2017:. Retrieved 2007: 1970: 1964: 1953:. Retrieved 1943: 1932:. Retrieved 1922: 1889: 1867:. Retrieved 1863:the original 1853: 1810: 1806: 1782:. Retrieved 1772: 1739: 1735: 1729: 1692: 1688: 1678: 1635: 1631: 1621: 1576: 1572: 1562: 1509: 1505: 1457: 1453: 1442: 1409: 1405: 1399: 1356: 1352: 1342: 1299: 1295: 1285: 1274:. Retrieved 1264: 1250: 1239:. Retrieved 1229: 1218:. Retrieved 1208: 1197:. Retrieved 1187: 1176:. Retrieved 1172:the original 1162: 1151:. Retrieved 1144:the original 1131: 1018: 1003: 994: 974: 951: 942: 934: 922: 886: 858: 837: 825:. The 2004 819: 772:intoxication 729: 708: 700: 684: 667: 660: 636: 625: 617: 601: 575:Demographics 573: 570:Demographics 560: 549: 532:chemotherapy 513: 477: 474:Test results 461: 453: 400: 393: 255:longitudinal 248: 240: 228: 224: 203: 199: 183: 177: 130: 122: 101: 82: 79: 54: 50: 46: 44: 27:Medical term 4961:Wikiproject 4750:Venereology 4695:Neonatology 4592:Dermatology 4447:Gynaecology 4439:gynaecology 4422:Pulmonology 4240:Eye surgery 4202:Specialties 4151:WikiProject 4068:Philippines 4053:New Zealand 3909:Telenursing 3859:Orthopedics 3789:Home health 3502:Generalists 3383:Telenursing 3203:Blue Button 3175:health care 3173:In absentia 3023:Apgar score 2972:GALS screen 2857:Respiratory 2785:Temperature 2777:Vital signs 2674:Medications 2545:MedlinePlus 2330:(9): 1126. 2034:45 CFR 1973:. Chicago: 1579:(9): 1490. 1072:Medical law 889:outsourcing 855:Destruction 770:illness or 768:psychiatric 764:emancipated 436:vital signs 372:vaccination 300:pregnancies 236:Mayo Clinic 4996:Categories 4723:Psychiatry 4709:(PM&R) 4702:Phlebology 4690:Pediatrics 4517:Anatomical 4482:Diagnostic 4462:Obstetrics 4412:Nephrology 4397:Hematology 4392:Geriatrics 4385:Hepatology 4370:Cardiology 4360:Immunology 3995:By country 3864:Pediatrics 3844:Obstetrics 3804:Management 3794:Hyperbaric 3779:Geriatrics 3600:Pediatrics 3493:Levels of 3256:Health 2.0 2926:Liver span 2790:Heart rate 2767:Percussion 2752:Inspection 2705:Mnemonics 2233:2022-04-05 2209:2017-10-16 2134:: 415–31. 2019:2012-04-14 1955:2018-09-25 1934:2018-09-25 1869:2012-04-14 1784:2012-04-14 1296:The Lancet 1276:2012-04-14 1241:2012-04-14 1220:2012-04-14 1199:2012-04-14 1178:2012-04-14 1153:2012-04-14 1124:References 904:, to hide 598:Production 588:occupation 528:pacemakers 397:specialist 338:asbestos). 145:SOAP notes 45:The terms 4911:Physician 4795:education 4653:Neurology 4648:Narcology 4512:Pathology 4490:Radiology 4365:Angiology 4329:Andrology 4028:Hong Kong 4008:Australia 3819:Midwifery 3759:Emergency 3754:Education 3719:areas of 3639:licensure 3633:Education 3251:E-patient 2918:Abdominal 2762:Palpation 2669:Allergies 2464:145754009 2456:1064-2684 2397:2291-9694 2273:2574-3805 1993:cite book 1908:cite book 1827:0002-9343 1764:133142770 1756:1574-0137 1742:: 45–61. 1652:1558-0032 1595:1660-4601 1536:0027-8424 1426:0895-4356 1373:0003-4967 1316:0140-6736 1237:. Hhs.gov 1195:. Nih.gov 1077:OpenNotes 1052:Bioethics 1022:anamnesis 989:talk page 906:birth sex 492:pathology 484:radiology 464:SOAP note 335:community 296:obstetric 263:illnesses 4941:Category 4417:Oncology 4348:medicine 4346:Internal 4194:Medicine 4127:Category 4063:Pakistan 4057:timeline 4012:timeline 3904:Surgical 3854:Oncology 3834:Neonatal 3829:Military 3784:Holistic 3774:Forensic 3721:practice 3610:Neonatal 3495:practice 3051:Pap test 3016:Neonatal 2742:General/ 2723:COASTMAP 2415:35687381 2291:30646219 2184:(c91W). 2140:12041089 1845:27288854 1721:31152528 1670:22287248 1613:31035551 1554:20385806 1484:29924316 1391:26582823 1334:35065702 1029:See also 983:You may 898:Intersex 760:comatose 751:capacity 746:Capacity 584:religion 504:findings 376:immunity 354:exercise 352:intake, 259:diseases 196:Contents 4981:Outline 4951:Commons 4896:Therapy 4793:Medical 4356:Allergy 4324:Urology 4217:Surgery 4139:Commons 4107:history 4097:history 4023:Germany 3963:systems 3734:Cardiac 3486:Nursing 3338:eHealth 3271:mHealth 2835:Hearing 2406:9233261 2337:1229252 2282:6324595 2177:Hansard 2168:Moyle R 2037:164.526 1836:7098183 1712:6658290 1661:3779068 1604:6540163 1545:2867915 1514:Bibcode 1475:6148967 1434:9250271 1382:5049504 1325:8841637 1112:Nursing 1107:Midwife 956:Privacy 867:case). 838:In the 736:consent 730:In the 685:In the 626:In the 602:In the 522:forms, 494:(e.g., 350:alcohol 346:tobacco 286:surgeon 278:surgery 108:ethical 106:, many 104:privacy 59:patient 4971:Portal 4838:MD–PhD 4088:Taiwan 4018:Canada 3894:School 3809:Matron 3769:Flight 3749:Dental 3590:Family 3314:PubMed 3066:Sports 2897:Other 2714:OPQRST 2709:SAMPLE 2561:(EPIC) 2462:  2454:  2413:  2403:  2395:  2334:  2289:  2279:  2271:  2138:  1981:  1896:  1843:  1833:  1825:  1762:  1754:  1719:  1709:  1668:  1658:  1650:  1611:  1601:  1593:  1552:  1542:  1534:  1482:  1472:  1432:  1424:  1389:  1379:  1371:  1332:  1322:  1314:  925:felony 908:, and 871:Abuses 842:, the 816:Canada 792:audits 675:access 661:Under 496:biopsy 488:X-rays 445:etc.). 356:, and 341:Habits 316:family 171:, and 75:X-rays 4553:Other 4083:Spain 4048:Kenya 4043:Japan 4033:India 3970:NANDA 3899:Space 3702:NCLEX 3084:RED-S 2845:Rinne 2840:Weber 2810:HEENT 2543:from 2460:S2CID 2203:(PDF) 2099:(PDF) 1975:AHIMA 1760:S2CID 1147:(PDF) 1140:(PDF) 805:case 643:HIPAA 348:use, 253:is a 112:legal 89:AHIMA 4038:Iran 3919:WOCN 3707:TEAS 3636:and 2744:IPPA 2719:SOAP 2631:and 2572:ASTM 2452:ISSN 2411:PMID 2393:ISSN 2287:PMID 2269:ISSN 2136:PMID 1999:link 1979:ISBN 1914:link 1894:ISBN 1841:PMID 1823:ISSN 1752:ISSN 1717:PMID 1666:PMID 1648:ISSN 1609:PMID 1591:ISSN 1550:PMID 1532:ISSN 1480:PMID 1430:PMID 1422:ISSN 1387:PMID 1369:ISSN 1330:PMID 1312:ISSN 887:The 879:The 582:and 580:race 430:The 405:SOAP 358:diet 314:The 294:The 288:did. 249:The 119:Uses 110:and 67:care 65:and 53:and 4287:ENT 4205:and 2585:or 2583:EHR 2579:XML 2487:doi 2444:doi 2401:PMC 2383:doi 2332:PMC 2328:158 2277:PMC 2261:doi 2182:921 1831:PMC 1815:doi 1811:129 1744:doi 1707:PMC 1697:doi 1656:PMC 1640:doi 1599:PMC 1581:doi 1540:PMC 1522:doi 1510:107 1470:PMC 1462:doi 1414:doi 1377:PMC 1361:doi 1320:PMC 1304:doi 1300:399 920:. 691:NHS 530:), 524:EKG 490:), 147:), 61:'s 4998:: 4626:/ 2557:- 2483:28 2481:. 2458:. 2450:. 2440:15 2438:. 2434:. 2409:. 2399:. 2391:. 2379:10 2377:. 2373:. 2354:. 2326:. 2322:. 2285:. 2275:. 2267:. 2255:. 2251:. 2212:. 2180:. 2174:. 2132:93 2130:. 2118:^ 1995:}} 1991:{{ 1910:}} 1906:{{ 1878:^ 1839:. 1829:. 1821:. 1809:. 1805:. 1793:^ 1758:. 1750:. 1740:32 1738:. 1715:. 1705:. 1693:21 1691:. 1687:. 1664:. 1654:. 1646:. 1636:16 1634:. 1630:. 1607:. 1597:. 1589:. 1577:16 1575:. 1571:. 1548:. 1538:. 1530:. 1520:. 1508:. 1504:. 1492:^ 1478:. 1468:. 1458:39 1456:. 1452:. 1428:. 1420:. 1410:50 1408:. 1385:. 1375:. 1367:. 1357:75 1355:. 1351:. 1328:. 1318:. 1310:. 1298:. 1294:. 912:. 610:. 518:, 482:) 217:. 175:. 167:, 163:, 159:, 155:, 151:, 139:, 135:, 49:, 4186:e 4179:t 4172:v 4109:) 4105:( 4099:) 4095:( 4059:) 4055:( 4014:) 4010:( 3478:e 3471:t 3464:v 3145:e 3138:t 3131:v 2621:e 2614:t 2607:v 2517:. 2493:. 2489:: 2466:. 2446:: 2417:. 2385:: 2340:. 2307:. 2293:. 2263:: 2257:1 2236:. 2156:. 2142:. 2101:. 2084:. 2052:. 2022:. 2001:) 1987:. 1958:. 1937:. 1916:) 1902:. 1872:. 1847:. 1817:: 1787:. 1766:. 1746:: 1723:. 1699:: 1672:. 1642:: 1615:. 1583:: 1556:. 1524:: 1516:: 1486:. 1464:: 1436:. 1416:: 1393:. 1363:: 1336:. 1306:: 1279:. 1244:. 1223:. 1202:. 1181:. 1156:. 1010:) 1004:( 999:) 995:( 981:. 811:. 784:) 774:. 364:. 143:( 42:. 20:)

Index

Patient record
electronic health record
Medical Record (journal)
Case Notes (radio show)
patient
medical history
care
healthcare professionals
X-rays
personal health records
AHIMA

privacy
ethical
legal
health care providers
admission notes
on-service notes
progress notes
SOAP notes
preoperative notes
operative notes
postoperative notes
procedure notes
delivery notes
postpartum notes
discharge notes
Personal health records
antimicrobial resistance
genome-wide association studies

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