Overview

medical record


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A file of information about a patient that usually consists of several categories of facts: 1. Personal identifying and basic sociodemographic information (name, age, sex, place of residence, occupation, next of kin); 2. Clinical information (symptoms, signs, test results, diagnoses, treatment regimens, progress notes, outcomes); 3. Economic and fiscal details (method of payment, insurance coverage); 4. Administrative data (site, institution, specialty of service); and 5. Behavioral data (evidence on adherence to treatment regimen, keeping or breaking appointments).

1. Personal identifying and basic sociodemographic information (name, age, sex, place of residence, occupation, next of kin); 2. Clinical information (symptoms, signs, test results, diagnoses, treatment regimens, progress notes, outcomes); 3. Economic and fiscal details (method of payment, insurance coverage); 4. Administrative data (site, institution, specialty of service); and 5. Behavioral data (evidence on adherence to treatment regimen, keeping or breaking appointments).

Subjects: Public Health and Epidemiology.


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