medical record

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ThesaurusAntonymsRelated WordsSynonymsLegend:
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
Based on WordNet 3.0, Farlex clipart collection. © 2003-2012 Princeton University, Farlex Inc.

med·i·cal re·cord

n. expediente médico, historia clínica.
English-Spanish Medical Dictionary © Farlex 2012
References in periodicals archive ?
SEHA was recognised for adopting Electronic Medical Record technologies in the world of healthcare to improve patient security, hospital efficiency and the safe supply of pharmaceuticals.
The Abu Dhabi Health Services Company (Seha) has implemented an advanced EMR (electronic medical record) functionality, which allows its physicians to view and share on a patients care regardless of the patient's location.
Medical record auditor; documentation rules and rationales, with exercises, 3d ed.
The director of radiology at a community hospital discusses the challenges involved in incorporating information from separate RIS and PACS into a single electronic medical record.
One of the greatest areas for improvement in information technology is in the implementation of an electronic health system based on the use of electronic medical records (EMR), also known as automated medical records and many other name such as clinical data repository, computer-based patient record, computer-based patient record system, computer-based patient record-type system, computerized medical record, computerized patient record, electronic health record, electronic patient record, lifetime data repository, virtual health record, or virtual patient record.
Not only was I changing area health services (I had previously worked for the Sydney West Area Health Service, at Lithgow Hospital) but my role would be manager of a medical record department that utilised a document imaging system in which medical records are scanned.
Medical-surgical nurses routinely enter data and notes, and add their signatures to the medical record at every patient encounter.
Hospitalized patients report many adverse events, some serious and preventable, that are not documented in the medical record. 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.
Because no current national identifier exists, most health systems use a technique known as statistical matching, which retrieves a patient's medical record by searching for attributes such as name, birth date, address, gender, medical record numbers, or Social Security number.
Although disputed by Gorney, her medical record reflected that she had been assisting her husband in performing a home improvement project the weekend prior to her office visit.
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.
A report in the journal Health Affairs said that if the United States were to use an electronic medical record system, the savings could be nearly $78 billion a year.

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