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 ?
Its legs being the patient, the practitioner, and the medical record.
The electronic medical record will enable those of us in ambulatory care to do the kind of quality-related activities that need to be done in our environment of rapidly increasing visits in spite of less than compensating resources.
These examples, among many others, illustrate how poor medical records can make it difficult for attorneys, expert witnesses, and risk managers to evaluate whether a claim is meritorious or frivolous.
Provide a secure chain-of-custody medical record moving procedure to ensure all medical records are safe before, during, and after the move
Our evaluation in two low-incidence areas of Georgia leads us to believe that the geographic variation in incidence found through medical record review cannot be entirely explained as an artifact of surveillance.
The public strongly supports the right to the privacy of the most sensitive information that exists about them--their medical records.
The HMO practice of routinely demanding patient medical records from doctors is also expanding the vast audience looking at patient records.
Medical records of Filipinos may soon be available through Information and Communication Technology under a bill establishing the Electronic Medical Records Center under the Department of Health (DOH).
I can think of 11 ways that health care will be able to change when digitized medical records, images, and lab results are standard and all medical devices and personnel are connected--with proper safeguards for privacy and accountability.

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