Medical records

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Abstract

Medical records are a means of recording details about a patient's care and communicating that information between healthcare professionals. The information contained within the medical records can also be used to monitor service activity, and for audit and research purposes. It is therefore essential that records are clear, accurate and legible, and that they are made contemporaneously (see Box 5.1).

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APA

Houghton, A. R. (2010). Medical records. In Chamberlain’s Symptoms and Signs in Clinical Medicine: An Introduction to Medical Diagnosis, 13th Edition (pp. 29–34). CRC Press. https://doi.org/10.5040/9781509967339.v1_ch-038

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