Health Records and Information Technology

A health record is a confidential compilation of pertinent facts of an individual’s health history, including all past and present medical conditions, illnesses and treatments, with emphasis on the specific events affecting the patient during the current episode of care.

Health records are also known as medical records, paper-based health records, clinical records, healthcare records, digitized health records, electronic health records, electronic medical records, and personal health records.

A medical record includes a variety of types of “notes” entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers. More