health record


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Related to health record: medical record, Electronic health record

health record

As used in the UK, a health record is a collection of clinical information pertaining to a patient's physical and mental health, compiled from different sources. Health records contain demographic data, next of kin, GP details, and most of the following: medical history; examinations; diagnoses; treatment (including surgical procedures and drug therapy); results of investigations—labs (e.g. biochemistry, haematology, pathology), imaging (e.g., plain films, scans); alerts and warnings (e.g., allergies, blood group, obligatory drugs, etc.); record of preventative measures (immunisations, screenings—breast, cervical, faecal, occult blood); nursing records; clinical correspondence and referrals for treatment; consent forms for surgical procedures; theatre reports; discharge letters; post-mortem reports. Health records are maintained by, or on behalf of, the health professional concerned with the patient's care and maintained as private documents under Caldicott guidelines.

health re·cord

(helth rek'ŏrd)
A comprehensive compilation of information traditionally placed in the medical record but also covering aspects of the patient's physical, mental, and social health that do not necessarily relate directly to the condition under treatment.
See also: record (1)
References in periodicals archive ?
He noted that among the benefits to primary care providers who adopt electronic health records and use them in a meaningful way are:
Last, but not least, the health record can serve to assure the student he is healthy.
Electronic health records have been the Holy Grail for people in health care and technology for 30 years.

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