medical record
Health history document
A medical record is documentation of a patient's health history, diagnoses, treatments, and clinical encounters.
Hospitals and clinics maintain medical records for continuity of care and legal purposes.
The doctor reviewed her medical record before the appointment.
Patients can typically request copies of their own records.
Able to wait calmly
- physicianLicensed medical doctor
- nurseHealthcare provider, bedside
- encounterUnexpected meeting or confrontation
- examinationMethodical assessment or review
consultation · treatment · prognosis · symptoms · diagnosis · hospitalization · admission · discharge
Identification of illness
- allergiesAdverse immune responses
- immunizationsInjections conferring disease resistance
- vital signsMeasurable life indicators
- lab resultsData from diagnostic analysis
procedures · treatment plan · family history · social history · chief complaint · demographics · test results · imaging studies
Data shown visually
- progress notesRecords of treatment sessions
- discharge summaryFinal hospitalization record
- transcriptionWritten version of speech
- notationSystem of written symbols
clinical notes · entry · form · report · assessment · evaluation · consent form · authorization
Medical privacy statute
- confidentialityQuality of protecting secrets
- consentVoluntary agreement given
- authorizationFormal permission granted
- access controlRestricting resource availability selectively
audit trail · de-identification · patient rights · encryption · password protection · compliance · redaction · secure messaging
Continued holding or possession
- storageSpace for keeping goods
- archivingStoring for long-term keeping
- filingStoring documents systematically
- catalogingSystematic organization into records
purging · destruction · microfilm · digitization · scanning · indexing · retrieval · amendment
Digital patient documentation
- EMRDigital health documentation system
- paper chartPrinted navigational document
- patient portalOnline medical account access
- databaseOrganized digital information collection
interoperability · e-prescribing · scanning · indexing · retrieval · backup · cloud storage · legacy system
patient
Able to wait calmly
- physicianLicensed medical doctor
- nurseHealthcare provider, bedside
- encounterUnexpected meeting or confrontation
examination · consultation · treatment · prognosis · symptoms · diagnosis · hospitalization · admission · discharge · follow-up
diagnosis
Identification of illness
- allergiesAdverse immune responses
- immunizationsInjections conferring disease resistance
- vital signsMeasurable life indicators
lab results · procedures · treatment plan · family history · social history · chief complaint · demographics · test results · imaging studies · surgical history
chart
Data shown visually
- progress notesRecords of treatment sessions
- discharge summaryFinal hospitalization record
- transcriptionWritten version of speech
clinical notes · notation · entry · form · report · assessment · evaluation · consent form · authorization · referral
HIPAA
Medical privacy statute
- confidentialityQuality of protecting secrets
- consentVoluntary agreement given
- authorizationFormal permission granted
access control · audit trail · de-identification · patient rights · encryption · password protection · compliance · redaction · secure messaging · disclosure
retention
Continued holding or possession
- storageSpace for keeping goods
- archivingStoring for long-term keeping
- filingStoring documents systematically
cataloging · purging · destruction · microfilm · digitization · scanning · indexing · retrieval · amendment · correction
EHR
Digital patient documentation
- EMRDigital health documentation system
- paper chartPrinted navigational document
- patient portalOnline medical account access
database · interoperability · e-prescribing · scanning · indexing · retrieval · backup · cloud storage · legacy system · data migration
- healthcaredoctors, nurses, hospitals, hospital, clinic
- hospitalhospital, admission, wards, ER, bed
- personal datafull name, first name, last name, middle name, date of birth
- life recordsautobiography, biography, birth certificate, death certificate, genealogy
- recordsGuinness, documents, album, death certificates, files
- medical diagnosisdiagnosis, symptom, symptoms, condition, disease
medical recordcriminal record
Log of past convictions
academic transcript · legal record · credit report · credit history · tax return
medical recordprescription
Medical dispensing authorization
treatment plan · care plan · prognosis · advance directive · referral
record, medicine, records, medical, medication, medicinal, medications, medically, biomedicine