A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records.

Recording of pertinent information concerning patient's illness or illnesses.

Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record.

Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online consumer health information that is relevant to the health conditions and treatments related to a specific patient.

The commitment in writing, as authentic evidence, of something having legal importance. The concept includes certificates of birth, death, etc., as well as hospital, medical, and other institutional records.

The creation and maintenance of medical and vital records in multiple institutions in a manner that will facilitate the combined use of the records of identified individuals.

The freedom of patients to review their own medical, genetic, or other health-related records.

Compilations of data on hospital activities and programs; excludes patient medical records.

Data collected during dental examination for the purpose of study, diagnosis, or treatment planning.

Longitudinal patient-maintained records of individual health history and tools that allow individual control of access.

Records of nutrient intake over a specific period of time, usually kept by the patient.

Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress.

Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons.