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medical record medical history: the case history of a medical patient as recalled by the patient
Ãâó: wordnet.princeton.edu/perl/webwn
medical record Histories, reports, diagnoses, prognoses, interpretations, and other data or records, written or electronic, that pertain to a patient
Ãâó: www.setnlegalservices.org/glossary.htm
medical record technician A technician who assists the medical record administrator by coding, analyzing, and preserving patients' medical records and compiling reports, disease indices, and statistics in health care institutions.
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medical record, problem-oriented SEE: problem-oriented medical record.
Ãâó:
medical record A written or electronic account of a patient's medical history, current illness, diagnosis, details of treatments, chronological progress notes, and discharge recommendations. This is a legal document the patient is entitled to read and is authenticated by the physician's signature. There are strict rules regarding the confidentiality of the medical record.
Ãâó: www.vpaweb.com/About/glossary/default.asp
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