DOC - Clinical Record Management
Management of clinical records
What the Medical Record Includes
It includes a summary of the patient record, the patient profile, the medical history, the current (stable) medication, the clinical cases and clinical encounters-visits.
According to the Electronic Health Record (EHR) terminology, a "Case" is not simply a momentary condition. On the contrary, it is an entire journey; from the moment the patient becomes ill until the final outcome. Think of it as a small journey that can last from a few days to considerably longer. During this "journey" the patient usually has multiple stops. These stops are called either "Visits" or "Medical procedures." These are the moments when the doctor and patient come into contact either for examination, treatment, or simply to discuss the progress of health. These meetings are often called "Encounters," a term that conveys the idea of interaction between doctor and patient. They are like small chapters in the story of the clinical case, each with its own significance in the evolution of the patient's health.
Furthermore, in the medical record we can embed multimedia and other documents that represent diagnostic results, laboratory tests, assessments for health progress, hospital discharge, surgical interventions, consent forms, medical reports and others. These in turn are connected to one or more digital medical documents that are related to the case and the patient's visit, and all together are classified and archived in the medical library.