what medical records..and who found ..., explain about it
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Records may be termed as any information and documents kept in a systematic, scientific and easy ways that help to receive the required data at the time of necessity.
Similarly, Medical record is also a systematized way of storing the required data, information and other relevant documents with the objective of making easy availability of necessary data at the time of its need.
Medical record consists of name of patient, address, age, sex, occupation, disease, modes of diagnosis and recommendations made the after by the concerned doctor in course of undergoing treatment. It helps patients to acquire the right and apt treatment. Moreover, it acts as a tool for the doctor who is looking into the patient.
When we talk of the development of medical record, we have to go back to the seventeenth century. In 1752 A.D. Benjamin Franklin set up a incorporated Hospital in Philadelphia in United State of America. This hospital is presently known as Pennsylvania Hospital. He introduced medical record by preparing file of special cases on which patients' name, admission date, discharge date etc. were written. In the same way, another hospital was opened in Boston in 1821 A.D. where a typical method of keeping relevant data was initiated. Separate files were opened for different individual patients in order to keep records. This process proved to be more helpful in finding the necessary data regarding the patients. Besides this, it helped in acquiring important facts that could make easier to take care for patients and to conduct the proper research work.
With the passage of time Medical record has been a backbone for developing a new dimension in the health sector in each of the countries in the world.
Similarly, Medical record is also a systematized way of storing the required data, information and other relevant documents with the objective of making easy availability of necessary data at the time of its need.
Medical record consists of name of patient, address, age, sex, occupation, disease, modes of diagnosis and recommendations made the after by the concerned doctor in course of undergoing treatment. It helps patients to acquire the right and apt treatment. Moreover, it acts as a tool for the doctor who is looking into the patient.
When we talk of the development of medical record, we have to go back to the seventeenth century. In 1752 A.D. Benjamin Franklin set up a incorporated Hospital in Philadelphia in United State of America. This hospital is presently known as Pennsylvania Hospital. He introduced medical record by preparing file of special cases on which patients' name, admission date, discharge date etc. were written. In the same way, another hospital was opened in Boston in 1821 A.D. where a typical method of keeping relevant data was initiated. Separate files were opened for different individual patients in order to keep records. This process proved to be more helpful in finding the necessary data regarding the patients. Besides this, it helped in acquiring important facts that could make easier to take care for patients and to conduct the proper research work.
With the passage of time Medical record has been a backbone for developing a new dimension in the health sector in each of the countries in the world.
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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.[1]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.
The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites.[2] This concept is supported by US national health administration entities[3] and by AHIMA, the American Health Information Management Association.[4]
Because many consider the information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal.[5] 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 patient, who may obtain copies upon request.
The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites.[2] This concept is supported by US national health administration entities[3] and by AHIMA, the American Health Information Management Association.[4]
Because many consider the information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal.[5] 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 patient, who may obtain copies upon request.
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