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 ?
First, 12% of medical charts designated for review were unavailable or did not have sufficient information, which might have resulted in sampling bias.
Counseling sessions were performed at the Survivor Clinic, so they might have been performed as part of the clinic visit without being documented in the medical chart.
The Medication Administration Record (MAR) is another important section of medical charts in hospitals and care centres where nurses register the ordered medications, route of administration, dose, schedule and each time a drug is given to a patient (exact time and date).
It followed, that before greeting patients in the waiting room, interacting with patients; obtaining their medical charts, revisiting patients' charts; after that, the area of specialty is managing patient safety while moving or directing patients, including weighing the patients.
For example, one mother reported being told nothing could be done for the newborn, while the medical chart indicated that various options were discussed at length.
The study, published in the journal Pediatrics, involved review of 960 randomly selected medical charts of children treated at 12 children's hospitals nationwide in 2002, representing a total of 6,806 patient-days.
Available to patients who go to hospitals and clinics that are registered with the portal site, the new service provides the patients with online access to their medical charts via the Internet.
The bases of the disclosures are medical charts, results of a post mortem examination and memoirs from physicians who treated Lenin and were sworn to secrecy after he died in 1924.
One of them, Charlie, didn't speak--although he did laugh--and his medical chart indicated that he had an attention span of less than ten seconds.
Methods: We conducted a chlamydia screening study (Phase 1) and retrospective medical chart review (Phase II) of 199 women from 16 to 40 years of age attending a primary care clinic in metropolitan Atlanta.
In a retrospective medical chart review over two consecutive winters, 45% of 229 children tested during the first season and 52% of 109 children tested during the second season had positive direct fluorescent assay (DFA) results; viruses identified included respiratory syncytial virus, parainfluenza 1, 2, and 3, and influenza A (Arch.
After noticing on a patient's medical chart that she was considering an abortion, he decided to offer advice to the woman and prayed with her.

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