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The Six Cs of Medical Records Clients Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.
Answer: A record is a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family or community.
There are three types of medical records commonly used by patients and doctors: Personal health record (PHR) Electronic medical record (EMR) Electronic health record (EHR)
A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.
The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
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Key components of an EHR Patient Management. The patient management component facilitates the capture, storage and retrieval of up-to-date information related to new patients. Clinical Component. Secure Messaging and Alerts. Financial Dashboards. Revenue Cycle Management (RCM)
A patient record is the repository of information about a single patient. This information is generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient (or with both).
​A health record is a confidential compilation of pertinent facts of an individuals 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.
A patients medical chart may contain different note types, documenting office or telemedicine visits (encounters) and patient calls, such as: Consultation notes. Second-opinion notes. Progress notes.
Some things include: Chief complaints. History of illness. Vital signs. Physical examination. Surgical history. Obstetric history. Medical allergies. Family history.

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