medical record

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Related to Medical chart: health chart

rec·ord

(rek'ŏrd),
1. In medicine or dentistry, a chronologic written account that includes a patient's initial complaint(s) and medical history, physical findings, results of diagnostic tests and procedures, any therapeutic medicines or procedures, and subsequent developments during the course of the illness.
2. In dentistry, a registration of desired jaw relations in a plastic material or on a device to permit these relationships to be transferred to an articulator.
[M.E. recorden, fr. O.Fr. recorder, fr. L. recordor, to remember, fr. re-, back, again, + cor, heart]

medical record

Etymology: L, medicare + ME, recorden, to report
that part of a client's health record that is made by physicians and is a written or transcribed history of various illnesses or injuries requiring medical care, inoculations, allergies, treatments, prognosis, and frequently health information about parents, siblings, occupation, and military service. The record may be reviewed by a physician in diagnosing the condition. See also chart.

medical record

The documents pertaining to a Pt's medical history, diagnoses and therapies, and status when last seen by health care providers. See Documentation, Hospital chart, Problem-oriented medical record, SOAP.

re·cord

(rek'ŏrd)
1. In dentistry or medicine, written account that includes a patient's initial complaint(s) and medical history, physical findings, tests results, any therapeutic medicines or procedures or treatment, and subsequent developments during illness.
Synonym(s): medical record.
2. In dentistry, registration of desired jaw relations in a plastic material or on a device to permit these relationships to be transferred to an articulator.

medical record,

n the portion of a patient's health record that is prepared by physicians and is a written or transcribed history of various illnesses or injuries requiring medical care, including inoculations, allergies, treatments, prognoses, and frequently health information about immediate family, occupation, and military service. Term can also be used by dental offices and clinics. See also health history.
References in periodicals archive ?
Few recalled being offered comfort end-of-life care, even when the discussion was noted in the medical charts.
The objectives of this study were to estimate the prevalence of chlamydia infection in women ages 16 to 40 years of age attending a primary care clinic (Phase I) and to determine chlamydia-screening practices at the clinic via a retrospective medical chart review (Phase II).
Third, the traditional medical chart is entered chronologically--each doctor begins writing where the previous entry ends.
Patients' medical charts list the days of a week and include rows on which physicians handwrite the names of drugs prescribed to patients.
By streamlining the flow of handwritten medical charts, the billing and reimbursement process becomes much more efficient.
From electronic medical charts to administrative medical computers, a medical image archiving system, and tablet device connectivity, Panasonic offers a wide range of solutions for managing medical information.
Despite the fact that this test was ordered, extensive examination of Heide's medical chart, along with related depositions of the hospital's medical records custodians, established conclusively that there were no preliminary or final reports from this culture in the final medical chart that was produced to the parties requesting Heide's medical records.
Thrower, as owner of Healthcare, did not adequately supervise Nurse Woolfolk or take steps to assure that she was supervised by a physician and did not thoroughly examine her or her medical chart.
Her surgeon agreed and the plan was documented in her medical chart.
MegaOak HR is an electronic medical chart system that promotes collaboration between hospitals while improving safety and convenience for patients.
He also addresses the nature of personal injury and malpractice cases, and the admissibility of the medical chart as evidence.
If SARS was not recorded as a possible diagnosis in the medical chart, despite SARS-defining manifestations for at least 24 hours of hospitalization, recognition of SARS was classified as late.

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