What it means
The official document of everything about a client's care: history, assessments, orders, medications, test results, notes and consent forms. Today it is usually an electronic health recordih-lek-TRON-ik HELTH REK-erdA digital version of a client's medical record that the care team can read and update on a computer.Full entry . It is a legal document used to share information among the care team, for billing, research and in court. The client's privacy is protected by law (HIPAA in the United States).
For the nurse
Document facts promptly and accurately, and never chart care before it is done. Look only at records of clients you are caring for, and never share your login.
At a glance
| Spanish | historia clínica, expediente médico |
|---|---|
| Also written | medical records |
Related terms
electronic health record
A digital version of a client's medical record that the care team can read and update on a computer.
medication reconciliation
Comparing a client's full list of current medicines with new orders at each change in care, to find and fix differences.