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

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 ?
Summary: ABU DHABI -- The Abu Dhabi Health Services Company (SEHA) has been awarded the prestigious 'Health Tech Innovation Award' for its Electronic Medical Records during ID World Abu Dhabi 2011.
The new software feature enables medical staff to easily access medical records from any location at any location.
How can these be viewed as one medical record when the information must be retrieved separately?
Role of multihospital system membership in electronic medical record adoption.
Basically, medical records are received in the Medical Record Department in the same manner as in a paper-based department.
Of particular concern is the scenario of a visit lasting 10-15 minutes and the medical record indicating a much longer visit.
Department of Health and Human Services awarded the grants to 34 states studying the implementation of electronic medical records.
The interagency program permits the secure, real-time exchange of medical record data between VA and DoD, thereby avoiding duplicate testing or even surgeries.
Health Minister Datuk Seri Dzulkefly Ahmad was previously reported to have said the electronic medical record (EMR) system that facilitates the transfer and sharing of patient information is expected to be implemented at 145 hospitals nationwide within the next three years.
In this simple scenario of a medical malpractice case, there is one piece of evidence that has the power to make-or-break the physician's case: the medical record. Unlike other types of evidence, the medical record is the only type that can be prepared fully and accurately before a lawsuit comes to fruition.
By November end, medical records of all patients will be available at the click of a button on the Salama Electronic Medical Records (EMR) system across all Dubai Health Authority hospitals in the emirate, said a top DHA official on Wednesday.
There was a significant difference between what a patient wrote on the questionnaire and what was ultimately recorded in their medical record. Of the group, there was "exact agreement" between a patient's survey and their medical record in only 38 cases.

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