patient record, a collection of documents that provides an account of each episode in which a patient visited or sought treatment and received care or a referral for care from a health care facility. The record is confidential and is usually held by the facility, and the information in it is released only to the patient or with the patient’s written permission. It contains the initial assessment of the patient’s health status, the health history, laboratory and radiological reports of tests performed, notes by nurses, physicians, and other health care professionals regarding the daily condition of the patient, and notes by consultants, as well as order sheets, medication sheets, admission records, discharge summaries, and other pertinent data. A problem-oriented medical record also contains a master problem list. The patient record is often a collection of papers held in a folder, but it may be computerized. Also called chart. See also medical record.
