Medical Record describes the systematic documentation of a single patient’s medical history and care across time within one particular healthcare provider’s jurisdiction.
It’s a chronological written account of a patient’s examination and treatment that includes patient’s medical history, complaints, physician’s physical findings, diagnostic test results, medications and therapeutic procedures.
Medical records serve many purposes- first and foremost it documents the history of examination, diagnosis and treatment of a patient which is vital for all providers engaged in patient’s care.
Maintaining medical records ensure continuity of care for the patient. These may also be required for legal purposes if, for example, the patient pursues a claim for an injury at work etc.