A file kept for each patient, maintained by the hospital, clinical, or medical provider that documents the patient’s problems, diagnostic procedures, treatment and outcome. Related documents (e.g., consent) are also included in the record. Additional information most often includes clinical, demographic, sociocultural, sociological, economic, administrative and behavioral data.
The contents of this glossary is funded in part through a sub-award from RTI as the lead partner for the National Institute of Justice’s Forensic Technology Center of Excellence through a Cooperative Agreement from the National Institute of Justice (2011-DN-BX-K564 and 2016-MU-BK-K110), Office of Justice Programs, U.S. Department of Justice. Neither the U.S. Department of Justice nor any of its components operate, control, are responsible for, or necessarily endorse, this website (including, without limitation, its content, technical infrastructure, and policies and any services or tools provided).