The Medical Transcriptionist’s Role With The Healthcare record Submitted By: Connie Limon The healthcare record is:•Chronological•Documents of a patient’s initial database •Initial evaluation•Identified problems and needs•Objectives of care•Prescribed treatment•Results The healthcare record belongs to the hospital, medical facility or office where it originated. It cannot be removed from the premises without a subpoena or court order.

Although much of the healthcare record is maintained through computer software systems, most medical care facilities still maintain a “paper” healthcare record of some sort.The healthcare record is maintained by the Health information Department of hospitals and medical facilities and usually headed by a registered record administrator or an accredited record technician.A former term for the healthcare record for over fifty years was


“Medical Record.” The new term of healthcare record denotes both illness and wellness. The Medical Record Department name has also changed to Health Information Department.What is the purpose of a healthcare record?It is a measurement and documentation of care rendered in a medical facility. The healthcare record is used to plan, communicate and evaluate the quality of care given to each patient. It provides “proof” of work done for each patient. Documents are required to meet federal, state, and JCAHO (Joint Click Here for the rest.