A medical record is that piece of paper or electronic file that contains all of your medical history: family traits, past ailments and injuries, things to which you are allergic, and so on. It is a very useful document indeed. Everybody's health and body is unique. Thus, everybody has different and unique health requirements. Medical records are maintained to help doctors know which medication and medical assistance is required for a particular patient. Medical records also include a written or electronic account of a patient's medical history, the illness though which the individual is currently going through, all the details of the medical treatments that were given, and so on. These records also provide a ready resource including chronological progress notes, and discharge recommendations. This provides a proper legal document which the patient is entitled to read and is authenticated by the physician's signature. Nevertheless, there are some strict rules laid down for it. One of them is the privacy of such legal medical documents. The kind of medical history a person holds, including the medical histories, diagnoses and medical interpretations that a medical record holds serves a great resource to track back the health intricacies of the particular person, but also contains a lot of information which the patient would like to keep out of the public eye. A medical record can be maintained in two ways: either by hand-written documents (but this requires a lot of time, is prone to error and makes storage a problem) or by electronic medical records (this is the latest state-of-the-art technology). |
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