Medical Notes

75Health EHR Software guarantees accurate and comprehensive medical notes that are stored on the cloud for easy access.

What is a Medical Note?

A medical note happens to be the entry made by a provider, nurse, or other member of the patient's care team, into the health record of the patient. Medical notes, when complete and accurate, make sure that the patient's medical data such as diagnosis, health record, and treatment are documented in a systematic manner.

Information stored in the medical note

Healthcare providers normally use medical notes to enter all the medically relevant events which have occurred in the patient's life since birth. These events may include minor and major illnesses, diseases, and growth landmarks. A clinician reading the medical note of a patient must be able to understand clearly everything that has happened to the patient previously. This proves vital to healthcare providers for diagnosing and managing the patient's disease or medical condition.
Medical notes include the following:
  • Family history
  • Surgical history
  • Obstetric history
  • Social history
  • Developmental history
  • Demographics
  • Medical encounters
  • Habits
  • Medications and allergies
  • Immunization records

Access to medical notes

The patient and the healthcare providers who are involved directly in the patient's care are allowed access to view the medical charts. The patient is the owner of the medical record, and it is the privilege of the patient to ensure the charts are accurate. Patient is entitled to grant access to other parties; they may petition the physicians to make amendments to inaccurate records, if any.

The Role of Electronic Health Record (EHR)

EHR ensure that medical notes are accurate and complete. Good EHR Software or system sees to it that providers are alerted about any incomplete, missing, or inaccurate immunization records.
EHRs also warrant that a patient's medical note is stored in an easily accessible location and is never lost. Healthcare professionals may ensure that all essential information are available for providing the most optimal care possible, while patients may ensure that they have access to their medical notes always.
Enabling instant access to critical health information, reducing treatment delays and duplication, offering information to patients for taking better decisions.
Reducing medical errors, improving the clarity and accuracy of medical records, and coordination of treatment and diagnosis among providers.
Allowing patients to access their own medical records and view lifetime health trends that empower them to arrive at proper decisions.