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Since I was assigned in a Medical Records Department supervised by Mr. Arjen Bagongon, let me give you a little background about it. The terms medical records, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care jurisdiction. The medical records includes a variety of types of "notes" entered over time by time health care professionals, recording observations and administrations of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a liscensing or certification prerequisite.
More about this? Click here.
https://en.wikipedia.org/wiki/Medical_record
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