Medical Records (Health Information Management)
The management of patient data is performed at the VTH by the Health Information Management Department. The department manages and processes patient information electronically via hardcopy formats. The compilation of this data is referred to as the medical record.
The medical record is the who, what, where, when and how of patient care. It chronicles the patient admission, treatment and clinical progress. It must be maintained to serve the patient, the health care providers, and the institution in accordance with legal, accrediting, and regulatory agency requirements.