medical record
Học thuậtThân thiện
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
- the case history of a medical patient as recalled by the patient