patiëntendossier

A patiëntendossier, also known as a medical record or patient chart, is a comprehensive collection of a patient's health information. It serves as a vital tool for healthcare professionals to track a patient's medical history, diagnoses, treatments, and progress over time. The dossier typically includes details such as personal identification, medical history, allergies, current medications, past illnesses and surgeries, laboratory results, imaging reports, and progress notes from consultations. It may also contain information about family medical history, lifestyle factors, and advance directives.

The primary purpose of a patiëntendossier is to ensure continuity and quality of care. By having all relevant information readily accessible, healthcare providers can make informed decisions, avoid redundant tests, and prevent medical errors. It facilitates communication and collaboration among different healthcare professionals involved in a patient's care, whether they are general practitioners, specialists, nurses, or therapists. In many countries, strict legal regulations govern the creation, maintenance, and access to patiëntendossiers to protect patient privacy and confidentiality. Patients generally have the right to access their own medical records, and requests for such access are typically handled according to established procedures. The evolution of technology has led to the widespread adoption of electronic patiëntendossiers (EPDs), which offer benefits such as improved legibility, easier data retrieval, and enhanced security features compared to traditional paper-based systems.