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 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 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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References in periodicals archive ?
Ultimately, the only efficient way to comply is by using a computer-based patient record (CPR) system, which can filter information by the user's need-to-know.
has signed a strategic marketing agreement with 3M Health Information Systems, to integrate Logician(R), MedicaLogic's market-leading ambulatory electronic medical record solution, with 3M Care Innovation software, a suite of care management products that forms a comprehensive computer-based patient record system.
Just imagine an e-mail with an attached patient record having the name of the patient changed or being sent to every tort lawyer in town.
HEALTH SYSTEMS GROUP JOINS COMPUTER-BASED PATIENT RECORD INSTITUTE
The computerized patient record (CPR) collects data across multiple episodes of care and facilitates data collection, presentation, and analysis through a clinical workstation.
A program is installed on a host computer that allows a user to selectively go and download a patient record to a notebook computer," explains Jim Ingalls, Vice President of Sales and Marketing at CARE.
15, 1992, on "CPR 2001: The Role of Computer-Based Patient Record Systems in Advancing Worldwide Health Care by the Year 2001.
A concern for the total loss of patient privacy accompanies the computerized patient record (CPR).
Nurses and physicians completing training have learned to use a computer-based patient record system to enter orders and retrieve laboratory results, at least for inpatients.
Assuming that the information systems plan will have as its core goal the creation of a computer-based patient record at every location of care for all patients of the OCS, the implementation plan will include establishing a governance structure for the planning and procurement of systems, for budgeting and raising capital, and for selecting and standardizing communication networks and transaction systems.
As part of Nash's vision of connecting its hospital with community physician offices and its affiliated hospice agency, the organization will deploy Misys' computer-based patient record system (Misys CPR(TM)), data sharing solution (Misys Connect(TM)), and clinical and business homecare and hospice solution (Misys Homecare(TM)).
The report of the Institute of Medicine Committee on Improving the Patient Record has stated clearly that there is no need for new technology breakthroughs to establish the computerized patient record.

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