medical chart
Clinical history file
A medical chart is the official record of a patient's health information maintained by healthcare providers.
It contains diagnoses, treatment history, test results, medications, and clinical notes.
Charts may be paper files in folders or electronic records in hospital databases.
Healthcare workers document encounters by charting—adding notes to the medical chart.
- patientAble to wait calmly
- diagnosisIdentification of illness
- chief complaintPrimary reason seeking care
- recordsStored data or albums
- vitalsBasic body measurements
notes · illegible handwriting · clipboard · doctor · nurse · nursing station · hospital · symptoms · vital signs · treatment · history · lab results · discharge · do not resuscitate · end of life · progress · bedside · pulse
- Emergency RoomER doctor, ER nurse, triage nurse, trauma bay, gurney
- clinicexam table, examination table, stethoscope, blood pressure cuff, otoscope
- doctor's officedoctor, appointment, checkup, exam room, examination table
- TV propsprop gun, fake money, rubber knife, evidence bag, case file
- anatomy diagramsanatomy poster, muscle diagram, body systems, labeled diagram, brain diagram
- health recordspatient history, vaccination record, vaccination records, immunization record, immunization card
medical chartprescription
Medical dispensing authorization
discharge instructions · doctor's orders · medical directive · care plan · referral
medical, chart, medic, medicine, medicinal, medically, medicate, medication, medicament