electronic health record

electronic health record

A computerised record of a person's health “transactions” in the UK, collated from summaries of individual electronic patient records and other relevant data. The ultimate goal is that every person in the UK will have a lifelong, data-protected EHR from birth to death, which will “travel” with them even if they change doctor or move around the country; EHRs will eventually replace paper patient records.

e·lec·tron·ic med·i·cal re·cord

(EMR) (ĕ-lek-tron'ik med'i-kăl rek'ŏrd)

A computerized (i.e., digitized) system for maintaining patient health information that generally includes patients' presenting (chief) complaints, history of prior illnesses, prior diagnostic testing, and prior medical treatments. Electronic records are used as a substitute for the traditional paper medical record; material is easier to access and update.
Synonym(s): electronic health record.

record

(rek'ord)

1. A written account of something. See: problem-oriented medical record

2. In dentistry, a registration of jaw relations in a malleable material or on a device.

anecdotal records

Notes used in nursing education to document observed incidents of a student's clinical behavior related to attainment of clinical learning objectives. Such anecdotal notes have not been treated as hearsay evidence in a court but have been upheld as documented evidence for failing a student.

electronic health record

Abbreviation: EHR
Electronic medical record.

electronic medical record

Abbreviation: EMR

A computerized database that typically includes demographic, past medical and surgical, preventive, laboratory and radiographic, and drug information about a patient. It is the repository for active notations about a patient's health. Most EMRs also contain billing and insurance information and other accounting tools.

Synonym: electronic health record

functional chew-in record

A record of the natural chewing action of the mandible made on an occlusion rim by the teeth or scribing studs.

interocclusal record

Bite plate.

medical record

A written transcript of information obtained from a patient, guardian, or medical professionals concerning a patient's health history, diagnostic tests, diagnoses, treatment, and prognosis.

medication administration record

Abbreviation: MAR

A file maintained on hospital units that documents the schedule and dosing of medications given to patients.

open medical record

A medical record accessible by the patient for his or her personal review.

personal health record

A summary of a patient's health care status (allergies, drugs taken, past hospitalizations, lab tests, radiology results, and surgeries) that is kept by the patient privately rather than stored in a hospital or third-party database.