What is a medical record?


Quick Answer

A medical record is a legal document that provides a patient's past care and medical history, as explained by Purdue University. A medical record contains information such as the patient's address, telephone number, past and pretend health status and more.

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Full Answer

A medical record also includes information such as the observations a health care provider has made about the patient's health, lab test results, current and past prescription medications, and the patient's past specialist referrals, according to Purdue University.

Electronic medical records are also in use and are considered an improvement over the traditional paper records, according to Partners Healthcare. More than one person may access a patient's electronic chart at the same time, and because they eliminate poor handwriting and enable the storage of additional information, electronic records are often organized better than paper records.

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