a collection of documents that provides an account of each episode in which a patient visited or sought treatment and received care or a referral for care from a health care facility. The record is confidential and is usually held by the facility, and the information in it is released only to the patient or with the patient's written permission. It contains the initial assessment of the patient's health status, the health history, laboratory and radiological reports of tests performed, notes by nurses, physicians, and other health care professionals regarding the daily condition of the patient, and notes by consultants, as well as order sheets, medication sheets, admission records, discharge summaries, and other pertinent data. A problem-oriented medical record also contains a master problem list. The patient record is often a collection of papers held in a folder, but it may be computerized. Also called chart. See also medical record.
patient recordPatient medical record A document relevant to Pt management–eg, medical Hx, chief complaint(s), diagnostic and therapeutic procedures performed and current status, usually arranged in chronologic order. See SOAP.
Patient discussion about patient record
Q. ex-wife works in hospital and accesses my and my familys medical records what can i/we do about this legally this is done without any consent she has computer acess to any records and accesses them upon her own
A. If you are sure of this she is breaking the law...Hippa protects patient right and this is a clear voliation of those right. I suggest you get a copy of the hospitals Right to Privacy , HIPPA paperwork. Then If you can prove this write a letter to hospital admenistration and one to her supervisor and/or director. Let them know you know this is a violation of patient rights and you want it dealt with immediatly or you will seek out legal council. They should responded to your letter in avery timely matter. If you do not have proof discuss with someone in medical record about the "need to know" bases and if ther eis no reason for her to know this information( she could be one tha thas to put it on your records) you would like to be assured she has no access to them and if she is doing a job that would give her the right ask that they please have someone else in the department handle you and your family dure to personal reasons. I encourage you to handle this in a very proffesiMore discussions about patient record