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The medical record, often referred to as the patient chart, is a document with comprehensive information about a patients health care encounter, as well as demographic, administrative, and clinical data. between staff members and as a single data access point for everyone involved in the patient's care.

What is Medical Charting? A medical chart is simply a complete record of a patient's clinical data and medical history.

Though the information belongs to the patient, the physical medical chart belongs to the provider. Because the provider uses its resources to create and reproduce a copy of the patient's medical chart, HIPAA allows the provider to charge a set amount to any requesting party.

Typically, patient charts include vitals, medications, treatment plans, allergies, immunizations, test results, patient demographics, diagnoses, progress notes and reports. All information in patient charts comes from nurses, lab technicians, physicians and other practitioners involved in the patient's care.

List of medical abbreviations: V AbbreviationMeaningVSvital signs versus visual snowVSDventricular septal defectVSRventricular septal rupture (see myocardial rupture)VSSvital signs stable visual snow syndrome50 more rows

What kind of information comprises a medical chart? Medical charts contain documentation regarding a patient's active and past medical history, including immunizations, medical conditions, acute and chronic diseases, testing results, treatments, and more.

Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication. If written correctly, notes will support the doctor about the correctness of treatment.

RTC. return to clinic (appointment for outpatient for next medical examination)