medical record

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Noun1.medical record - the case history of a medical patient as recalled by the patientmedical record - the case history of a medical patient as recalled by the patient
case history - detailed record of the background of a person or group under study or treatment
family history - part of a patient's medical history in which questions are asked in an attempt to find out whether the patient has hereditary tendencies toward particular diseases

med·i·cal re·cord

n. expediente médico, historia clínica.
References in periodicals archive ?
Accurate and thorough medical record documentation is crucial for professionals in all areas: lawyers and risk managers need to adequately defend physicians and their records; physicians and medical professionals need to keep thorough documentation to provide quality care; and insurance adjustors need the ability to use documentation when evaluating claims.
To Provide Medical Records Service To LKMC For The Period Of July I, 2014 Through June 30, 2015 ; Quarterly CQI/QA Activity Reports ; Emergency II Stat II Requests For Medical Records ; Routine Request For Medical Records ; Annual Certified Destruction Of Eligible Medical Records To Include Medical Record Destruction Charges ; Off Site Physical Storage Charge For Stored Medical Records Per Linear Foot ; Electronic Storage Charge ; Routine Requests For Medical Records Chart To Be Returned To LKMC ; Request For Return Of Medical Records Electronic ; Request For Pictures Scanned From Chart
Since sensitive information is kept on computers, in filing cabinets, and on other forms of media, Montgomery healthcare professionals must take extra precaution to protect their clients—especially when it comes to medical record moving and storage.
Among 998 study patients, 23% mentioned at least one adverse event during their interview, but only 11% had an adverse event based on medical record review.
MC4 integrates, fields, and supports a medical information management system for Army tactical medical forces, enabling a comprehensive, lifelong electronic medical record for all servicemembers, and enhancing medical situational awareness for operational commanders.
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.
I have had the privilege of seeing our electronic medical record evolve.
Today, federal law requires physicians to provide a patient with his or her medical record, upon request," said Cuellar.
In the past, the discharge planner would make a copy of the patient's medical record and fax it to the SNF--not a time-efficient task for someone who, more often than not, has a master's degree.
We could stop HMOs from commandeering patient files simply by passing a law requiring patient consent for any third party to see a medical record.

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