Medical Records

Code: DF-7000.5100

Programs that maintain and, where appropriate, provide access to the cumulative history of a person's interaction with the health care system such as the occasions on which they have been examined, evaluated or treated for an ailment. Included are medical history records, a longitudinal record of what has happened to a patient since birth including diseases, major and minor illnesses and growth history which can give a clinician a feel for what has happened before to a new patient; inpatient care medical records (hospital records) which generally include admission notes, on-service notes, progress notes, preoperative notes, operative notes, postoperative notes, procedure notes and discharge notes; and a patient's case history with a particular health care provider which usually includes information gained by a physician by asking specific questions, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination by medical personnel. In addition are electronic health records (or EHRs), a systematized collection of a patient's electronically stored health information in a digital format. EHRs may include a range of data including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information. EHR systems are designed to store data accurately and to capture the state of a patient across time. It eliminates the need to track down a patient's previous paper medical records and assists in ensuring data is up-to-date, accurate and legible. It also allows open communication between the patient and the provider, while providing privacy and security.

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