Patient records

What is meant by Patient records?

The term "patient records" refers to the comprehensive collection and management of all medical and administrative information about a patient. These records include important data on medical history, diagnoses, treatments, findings, medications, and other health-related information necessary for continuous medical care and support. Patient records can be in physical form (paper documents) or digital form (electronic health records).

Typical software functions in the area of "patient records":

1. Data Entry and Storage: Capture and management of all relevant patient information, including personal data, medical history, and contact details.
2. Treatment Documentation: Recording all medical procedures, diagnoses, findings, prescriptions, and treatments the patient has received.
3. Access Control and Privacy: Management of access rights to patient records to ensure that only authorized personnel can view and edit data, in compliance with privacy regulations.
4. Search and Filtering: Features for quickly searching and filtering patient data and documents based on various criteria such as date, diagnosis, or treatment type.
5. Integration of Results and Lab Findings: Incorporation of external findings, lab results, and imaging data into the patient record for a comprehensive view of patient health.
6. Reporting and Analysis: Generation of reports and analyses based on data stored in patient records, to support diagnostic and therapeutic decisions.
7. Appointment and Reminder Management: Management of appointments and automated reminders for upcoming medical exams or treatments.
8. Communication and Notes: Facility for communication between medical staff and the patient or among different doctors and therapists, as well as making notes and comments.
9. Archiving and Backup: Long-term storage and regular backup of patient records to prevent data loss and ensure information availability.
10. Reporting and Audit Functions: Creation of audits and reports to review the use and management of patient records, and to comply with regulatory requirements.