patient record

patient record,

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 radiologic reports of tests performed, notes by nurses and physicians 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 record

Patient 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 proffesi

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B cardiac output chart computer-based patient record COSTAR documentation encounter form energy output evaluation file flow sheet folder formative evaluation MedisGroups no code nursing audit output P.I patient medical record	Furthermore, administrative staff also spent a lot of time accessing patient records from previous visits. Lessons learned from a journey to EMR: the time and cost clinicians ... by Health Management Technology Worldwide Computer Products News-11 March 2009-IBM researchers trial smarter patient records in Danish hospital(C)1995-2009 M2 COMMUNICATIONS LTD http://www. IBM researchers trial smarter patient records in Danish hospital by Worldwide Computer Products News [ILLUSTRATION OMITTED] In Australia, doctors will have to turn over private patient records to auditors as part of a government crackdown on doctors who overcharge Medicare for their services. Australian doctors must turn over patient records by Information Management Journal	pathya patient patient advocate patient assignment patient autonomy patient Bill of Rights patient care committee patient care technician patient compensation fund Patient compliance patient confidentiality patient contracting patient cooperation patient day patient dumping patient educatlon patient empowerment patient history patient informatics patient interview patient load patient medical record patient mix patient plan of care patient population patient record patient release criteria patient representative patient representative services Patient Right to Know Act patient rights protection Patient Self-Determination Act patient tracking patient viewpoint standard Patient Zero Patient's Bill of Rights patient-controlled analgesia patient-controlled analgesia assistance patient-initiated lab testing patient-oriented evidence that matters patient-physician relationship Patrick Swayze Tumour Patrick test Patrick's test patrilineal patroclinous patten Patterdale terrier pattern pattern and organization pattern of disharmony	patient movement requirements center patient movement requirements center Patient Navigator Research Program patient of Patient of the Month Program Patient of the Week Patient Office Visit Patient or Significant Other Patient Oriented Evidence that Matters Patient Oriented Research Patient Outcomes Research Team Patient Own Drugs Patient package insert Patient package insert Patient Participation Group Patient Perception of Bladder Condition Patient Placement Patient Plan of Care Patient Plan of Care patient population patient position for bisecting-angle technique Patient Positioning Sensor Unit Patient Positioning System Patient Privacy Rights Patient Privacy Rights Foundation Patient Protection and Affordable Care Act of 2010 Patient Reader Necessary patient record Patient Record Architecture Patient Record Data Systems Patient Record Database Patient Recruitment and Public Liaison Patient Referral Unit Patient Refined Expectations for Deciding Invasive Cardiac Treatments Patient refusal of nutrition and hydration Patient Relationship Manager patient release criteria Patient Report Form Patient Reported Outcome Patient Reported Outcome Measurement Study Patient Reported Status and Experience Survey Patient Reporting Activity patient representative patient representative services Patient Resource Office Patient Results Online Patient Revenue Management Organization Patient Right to Know Act Patient rights Patient rights Patient rights Patient rights patient rights protection patient rights protection patient rights protection patient rights protection patient role Patient safety

Mentioned in

References in periodicals archive

Medical browser

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B
cardiac output
chart
computer-based patient record
COSTAR
documentation
encounter form
energy output
evaluation
file
flow sheet
folder
formative evaluation
MedisGroups
no code
nursing audit
output
P.I
patient medical record

Furthermore, administrative staff also spent a lot of time accessing patient records from previous visits.

Lessons learned from a journey to EMR: the time and cost clinicians ... by Health Management Technology

IBM researchers trial smarter patient records in Danish hospital by Worldwide Computer Products News

[ILLUSTRATION OMITTED] In Australia, doctors will have to turn over private patient records to auditors as part of a government crackdown on doctors who overcharge Medicare for their services.

Australian doctors must turn over patient records by Information Management Journal

patient Bill of Rights

patient care committee

patient care technician

patient compensation fund

Patient compliance

patient confidentiality