The keeping of a clinical record of the important facts about a patient and the progress of their illness and or recovery. The patient’s chart most often contains a medical history, results of physical examinations, laboratory reports, results of special diagnostic tests, and the observations of the therapist, along with the long and short range goals.
A medical record, health record, or medical chart in general is a systematic documentation of a single client’s long-term, individual medical history, care and progress.
The term ‘Medical record’ is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient’s health history. Medical records are intensely personal documents and there are many ethical & legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal.
Although medical records are traditionally compiled and stored by health care providers, personal health records, (PHR) maintained by individual patients have become technically available and popular in recent years. This concept is supported by US national health administration entities, and by AHIMA, the American Health Information Management Association.
Despite the ownership of any special data container and for any tool providing access to the health record, the proprietor of the information is just the patient himself. No clause in the service contract with the patient may countermand this proprietary ownership. As a massage therapist, you are the keeper of the records.