The electronic health record (ehr) helps prevent medication errors by preventing medications from being administered to clients with allergies
The phrases medical record, health record, and medical chart are used interchangeably to represent the systematic documentation of a single patient's medical history and care across time within the jurisdiction of a single health care provider.
A medical record contains a variety of "notes" entered throughout time by healthcare professionals, noting observations and administration of drugs and therapies, orders for drug and therapy administration, test results, x-rays, reports, and so on. Health care professionals are required to keep complete and accurate medical records, which is usually enforced as a license or certification requirement.
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