patient’s records

See the following -

An Argument for Standardized Reference Terminologies

As a National Institutes of Health (NIH) article explains, standardized data is ‘crucial for data exchange between health information systems, epidemiological analysis, quality and research, clinical decision support systems, administrative functions.” Terminology is an important part of medicine. In short, it is a clinicians’ extensive healthcare vocabulary, which they use to describe a patients’ conditions and health events. With the onset of EHRs, clinicians are responsible for documenting patient information in EHRs. This is now properly done with standardized reference terminologies and not home-grown ones.