record

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record

 [rek´ord]
1. a permanent or long-lasting account of something, such as in writing or on film.
2. in dentistry, a registration.
bibliographic record an index record standing for or representing a journal article, book, or other document.
Problem-Oriented record (Problem-Oriented Medical record) see problem-oriented record.

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]

record

/rec·ord/ (rek´erd)
1. a permanent or long-lasting account of something (as on film, in writing, etc.).
2. in dentistry, a registration.

problem-oriented record  (POR) a method of patient care record keeping that focuses on specific health care problems and a cooperative health care plan designed to cope with the identified problems. The components of the POR are: data base, which contains information required for each patient regardless of diagnosis or presenting problems; problem list, which contains the major problems currently needing attention; plan, which specifies what is to be done with regard to each problem; progress notes, which document the observations, assessments, nursing care plans, physician's orders, etc., of all health care personnel directly involved in the care of the patient. See also SOAP.

record

[rek′ərd]
a written form of communication that permanently documents information relevant to the care of a patient.

record

Graduate education-UK
Conference of Postgraduate Medical Deans record, see there.

Lab medicine-UK
Data placed on a form which provides evidence of fulfilment of intent.

record

Medtalk A permanent document in the form of a writing, files, photographs, etc. See Electronic medical record, Medical record, Medical administration record, Open record, Patient record, Problem-oriented medical record, Sealed record. Cf Chart.

re·cord

(rek'ŏrd)
1. A chronologic written account that includes a patient's initial complaint(s) and medical history, the physician's physical findings, the results of diagnostic tests and procedures, and any therapeutic medications or procedures.
Compare: health record
2. 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.
3. To place in a graph (e.g., electrocardiogram) automatically.

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.

record

a permanent or long-lasting account of something (as on film, in writing, etc.); see also medical records.

Patient discussion about record

Q. ex-wife works in hospital and accesses my and my familys medical records what can i/we do about this legally this is done without any consent she has computer acess to any records and accesses them upon her own

A. If you are sure of this she is breaking the law...Hippa protects patient right and this is a clear voliation of those right. I suggest you get a copy of the hospitals Right to Privacy , HIPPA paperwork. Then If you can prove this write a letter to hospital admenistration and one to her supervisor and/or director. Let them know you know this is a violation of patient rights and you want it dealt with immediatly or you will seek out legal council. They should responded to your letter in avery timely matter. If you do not have proof discuss with someone in medical record about the "need to know" bases and if ther eis no reason for her to know this information( she could be one tha thas to put it on your records) you would like to be assured she has no access to them and if she is doing a job that would give her the right ask that they please have someone else in the department handle you and your family dure to personal reasons. I encourage you to handle this in a very proffesi

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