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What is Medical Record, Health Record, or Medical Chart

Handbook of Research on Developments in E-Health and Telemedicine: Technological and Social Perspectives
A systematic documentation of a patient’s medical history and care. The term ’Medical record’ is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient’s health historyy
Published in Chapter:
Information System for Management of Organisation and Its Activity
Lorenzo Ros McDonnell (Universidad Politécnica de Cartagena, Spain) and Salvador Guillen Salazar (Hospital General de Sagunto, Spain)
DOI: 10.4018/978-1-61520-670-4.ch024
Abstract
Health care organization management needs modeling techniques that allows to explain and manage it as the real world it self. This similarity between real world and model represents the key of success. A model characteristic represents the guide lines to manage it, and if this model is represented with a data model and an Information system it makes possible to be implemented in a computer based system. This chapter offers a hierarchical representation model and with different model views of the health care organizations, allowing being applied the business integration architecture, it is a way to transfer the organization approaches from the Industrial world to the Health Care world. To reach it is necessary to represent all the activities performed by a health care organization with the process map, linking the map with the structures of the organization that connects the different map points (resource-operation), developing the organization model. It is necessary that the decision making rules are implemented in the organization model to include in it the “intelligence”. The decision making rules to reach the organization rules are the Planning and Operation control system, and though it can be integrated the goals, activity and resources.
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