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.

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 ?
When moving, healthcare professionals should hire reputable medical record movers who comply with all state and federal privacy and security regulations during moving and storage.
We identified medical records for 706 patients with a diagnosis of botulism from eight hospitals in five regions of Georgia.
However, as alluded to by several authors in your health care technology issue, it was not until the physicians saw past the initial learning curve did the realization of the electronic medical record goal become achievable.
Assigning confidential log-in IDs and passwords to three SNF personnel--the admissions coordinator, the assistant DON, and the assistant administrator--allowing them access to the hospital's medical records of patients being referred.
The HMO practice of routinely demanding patient medical records from doctors is also expanding the vast audience looking at patient records.
Medical Records Online is the market leader of in-house, Release of Information (ROI) solutions for healthcare providers.
There is a pressing need for individuals and organizations to obtain medical records lost during the recent national disasters in the Gulf region," said Amy Rees Lewis, CEO of MediConnect.
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.
Setting up manual or computer indexing systems, assuring the timely completion of the medical record, helping to determine the projected information management needs of the facility and validating the accuracy of data are a few examples of how the HIM professional assists with the implementation of this function as outlined in the JCAHO standards.
Since New York does not require hospitals to release medical records to patients, his case was thrown out of court.
SMC) has selected MicroMD EMR as its electronic medical record system.

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