Definition

Noun: 1. A systematic documentation of a patient's health information: A "medical record" is a detailed, chronological file containing the history of a patient's health, including illnesses, diagnoses, tests, treatments, and outcomes, as maintained by healthcare providers. 2. The patient's own account of their health history: In some contexts, it can refer specifically to the history of a medical patient as recalled and reported by the patient themselves.

Usage Examples

• As a provider-maintained file:
  • The doctor reviewed the patient's medical record before the appointment.
  • Hospitals are required to keep medical records confidential.
• As a patient's recollection:
  • The form asks you to provide your medical record, including all past surgeries and allergies.

Advanced Usage

• "Electronic Medical Record (EMR)": A digital version of a patient's paper chart, containing the medical and treatment history within one healthcare provider's practice.
  • Most clinics have now transitioned from paper files to an Electronic Medical Record system.
• Legal and administrative context: The term is often used in discussions of privacy, data security, and healthcare administration.
  • Access to the medical record was crucial for the insurance claim.

Variants and Related Words

• Health record: A broader term that can include medical records as well as wellness and lifestyle data.
• Patient chart: A common synonym used within clinical settings, often referring to the active file during a hospital stay or visit.
• EMR (Electronic Medical Record): The digital form, as defined above.
• EHR (Electronic Health Record): A more comprehensive digital record designed to be shared across different healthcare settings.

Synonyms

• Patient file
• Clinical record
• Health history (when referring to the documented information)

Related Phrases

• To update a medical record: To add new information to the file.
  • The nurse will update your medical record with today's vital signs.
• To release medical records: To formally authorize the transfer of a medical record from one entity to another.
  • You must sign a form to release your medical records to the new specialist.

Noun

1. the case history of a medical patient as recalled by the patient