The healthcare record is:
0Chronological
0Documents of a patient0s initial database
0Initial evaluation
0Identified problems and needs
0Objectives of care
0Prescribed treatment
0Results
The healthcare record belongs to the hospital, medical facility or office where it originated. It cannot be removed from the premises without a subpoena or court order. Although much of the healthcare record is maintained through computer software systems, most medical care facilities still maintain a 0paper0 healthcare record of some sort.
The healthcare record is maintained by the Health Information Department of hospitals and medical facilities and usually headed by a registered record administrator or an accredited record technician.
A former term for the healthcare record for over fifty years was 0Medical Record.0 The new term of healthcare record denotes both illness and wellness. The Medical Record Department name has also changed to Health Information Department.
What is the purpose of a healthcare record?
It is a measurement and documentation of care rendered in a medical facility. The healthcare record is used to plan, communicate and evaluate the quality of care given to each patient. It provides 0proof0 of work done for each patient. Documents are required to meet federal, state, and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) standards and regulations. In addition the documents contained […]

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