the means by which information about health events from several different sources (e.g. hospital attendance, vaccination, and consultation with general practitioners) are all related to a specific individual in a common file or more usually a computerized record. This contrasts with data in which events only are recorded (see Hospital Episode Statistics) and two individuals treated for the same disease cannot be distinguished from one individual treated on two separate occasions.
A file kept for each patient, maintained by the hospital (medical practitioners also maintain medical records in their own practices), which documents the patient’s problems, diagnostic procedures, treatment and outcome. Related documents, such as written consent for surgery and other procedures, are also included in the record. In addition to facts about a patient’s illness, medical records nearly always contain other information such as clinical, demographic, sociocultural, sociological, economic, administrative and behavioural data. The record may be on paper or computerized.... medical record
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