medical record

medical record

n.

A chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the physician's physical findings, the results of diagnostic tests and procedures, and medications and therapeutic procedures.

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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.

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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.

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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.