medical record


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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.
References in periodicals archive ?
For years, patients and their attorneys have abided by the old adage: "If it's not written in the medical record, then it didn't happen.
Provide a secure chain-of-custody medical record moving procedure to ensure all medical records are safe before, during, and after the move
Medical records were available for 83 of the reported 173 patients from the 1994 outbreak.
As hospitals and clinics switch to electronic recordkeeping, access to private medical records will soon be very easy for anyone with a computer and Internet access.
The bill died in 1994, but the dream of a central information depot with cradle-to-grave medical records on all Americans lived on.
In each case, the privacy notices did not inform patients about how to exercise their rights to prevent access to their medical records under state statutory and common law.
Worse, these actions have been taken on the basis of medical records that-- without any input from the patient--are often misleading and sometimes inaccurate.
Give the medical record to the patient in software.
An electronic medical record is available 99 percent of the time and multiple people can access it simultaneously.

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