What are medical charts?
Documentation of a patient’s clinical data and medical history is done in all healthcare practices. These are called medical charts and utmost care is taken to maintain and systematically update them since physicians take important decisions based on these records.
Medical charts / medical records/health records must be accurate and complete, explaining the history, diagnoses and treatments provided in a detailed manner over the period of time the service was provided so that it can be accessible by different physicians for immediate reference. It will also include telemedicine visits. Therefore, a patient’s medical chart may include notes from one or multiple providers.
The electronic health record (EHR) or electronic medical record (EMR) has made the upkeep of medical records easier. EMR includes
- Patient demographics, eg; date of birth, gender, race etc.
- Medical visits providing details about the services provided, the diagnosis and follow-ups.
- Patient analysis data like labs, x-rays etc.
- Medications taken.
- Medical, family and social histories.
Therefore, medical charts provide complete details needed by physicians to treat a patient without which emergency treatments could become difficult and dangerous.