medical record

(redirected from Medical chart)
Also found in: Dictionary, Thesaurus.
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]
Farlex Partner Medical Dictionary © Farlex 2012

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.
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

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 Dictionary for the Dental Professions © Farlex 2012
References in periodicals archive ?
Zhang, "External validation of medicare claims for breast cancer chemotherapy compared with medical chart reviews," Medical Care, vol.
For all registered patients, we abstracted detailed information from medical chart of the index hospitalization (case report form shown in [Supplementary material 2 [SUPPORTING:2]] and data dictionary shown in [Supplementary material 3 [SUPPORTING:3]]).
Figure 2 shows the accessibility of patient by phone contact in order to obtain his or her weight if it was missed in the medical chart. All patients who had weight, age and serum creatinine information in their charts at the time of treatment (26 patients, 51%) had appropriate Oseltamivir dosing based on their renal functions.
The statement recommends quality measures based on: Validated risk-adjustment models for mortality and major complications 30-day mortality, to follow patients after they leave the hospital Clinical data taken from patients' medical charts, not claims information intended for billing purposes currently used by many quality programs Data collected in a nationally or regionally benchmarked database
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.
The entries are interspersed with snippets from her medical chart. Johns details the chilling physical harm a nine-year eating disorder will wreak, as well as the mental anguish she and the other patients dealt with on a day-to-day basis.
Kenda's had high-quality veterinary care from Tufts, and has lived to an advanced age with a mostly unremarkable medical chart - a root canal here, a sore toe there and last year's possible back problem that gave caretakers a scare.
Pertussis case status and vaccination status were ascertained by medical chart review.
Researchers determined current and past DSM-IV diagnoses based on results of the Mini-International Neuropsychiatric Interview, confirmed diagnoses with medical chart reviews, and assessed legal problems using court records and the treatment services review.
In-depth interviews with 26 mothers of babies who died shortly after birth at three mid-Atlantic hospitals revealed that what mothers said they were told by doctors was often at odds with what physicians recorded in the medical chart with respect to options offered and accepted.
Each medical chart was checked for an occurrence, or flag, that would "trigger" further investigation to determine the presence or absence of an adverse drug event.

Full browser ?