12/31/2023 0 Comments Locate pediatric medical records![]() An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation. ![]() ![]() The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request. Ī medical record folder being pulled from the recordsīecause many consider the information in medical records to be sensitive private information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association. Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites. The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite. 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 terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. ![]() For the BBC Radio 4 medical programme, see Case Notes (radio show). For the New York journal published by the Washington Institute of Medicine, see Medical Record (journal). For digital records, see electronic health record. The relevant legislation supporting parents/carers application for access to their child’s medical record is the Hospital and Health Boards Act 2011, Queensland Health’s Policy of Administrative Access to Health Records (1994), Queensland’s Information Privacy (IP) Act 2009 and the Right to Information (RTI) Act 2009.This article is about the documentation of a patient's medical history. The processing timeframe for RTI/IP applications for children’s records is 25 business days – you will be contacted if a longer time is required for processing. Please note: Access to children’s medical records will be assessed according to the guidelines in the Information Privacy Act 2009. Please send the completed form and required documents to:Ĭ/o Children’s Health Queensland Health Information Services ![]()
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