Medical Record | Practical Law

Medical Record | Practical Law

Medical Record

Medical Record

Practical Law Glossary Item w-030-1717 (Approx. 2 pages)

Glossary

Medical Record

All the documentation and data regarding any health care items or services provided to a patient during any aspect of health care delivery by any type of health care organization. All inpatient facilities (including hospitals, long-term care facilities, and rehabilitation facilities), outpatient facilities (including physician groups, ambulatory surgery centers, and outpatient clinics), and medical professionals (including physicians and non-physician practitioners (NPPs)) must keep medical records for their patients. For more information on medical records, see Standard Document, Medical Record Documentation Policy.