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Medical record

A document holding a patient's identity, examinations, treatment, procedures and other services given to them.

Minister of Health Regulation No. 24 of 2022 on Medical Records governs medical records, including electronic ones, in health facilities: what they hold, how they are kept, who may access them and the duty to keep them confidential. The record stays in the clinic's proper system and is opened only by people entitled to it for the purposes the rules allow. Its contents are not pasted, summarised or uploaded into a general AI service. This is a general picture; check the official text and your clinic's policy.

Also called: Medical record, medical records, electronic medical record

Appears in 4 lessons