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A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
A medical record includes a variety of types of "notes" entered over time by healthcare 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 ...
A medical certificate or doctor's certificate[ 1][ 2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [ 3] It can serve as a sick note ( UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition.
Medication Administration Record. A Medication Administration Record[ 1] ( MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical ...
Progress note. Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [ 1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP ...
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [13] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
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