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Health record

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Definition Edit

A health record (also known as a medical record) is the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. A health record includes a variety of types of "notes" entered over time by health care 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 health records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.


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