Okuzeka
Healthcare Management vocabulary · Medical Records and Health Information

Medical record

Meaning in healthcare management, with examples

nounCore term

In healthcare management, medical record means: The official record of a patient's health and care, including their history, diagnoses, test results, treatments and the notes written by staff.

In Turkish: tıbbi kayıt, hasta dosyası, hasta kaydı

How it is used

Often plural: medical records. Hospitals have a medical records department that stores, finds and archives them. Staff update, access and review records, and patients can ask for copies under data protection law. British English also uses 'health records' and 'patient notes'.

Example sentences

  1. The auditors checked fifty medical records to see whether consent forms had been signed.

  2. Only staff directly involved in a patient's care may access their medical records.

Common collocations

  • medical records department
  • access medical records
  • update a medical record
  • paper medical records
  • request medical records
  • electronic health recordA digital version of a patient's health record that authorised staff can view and update, and that can often be shared between departments and providers.
  • confidentialityThe duty to keep patients' personal and medical information private and to share it only with people who need it for their care or have legal permission.
  • discharge summaryA document written when a patient leaves hospital that summarises the diagnosis, treatment, medicines and follow-up plan, mainly for the patient's family doctor.
  • clinical codingThe process of turning the diagnoses and procedures in a patient's record into standard codes, which are used for payment, statistics and planning.

More terms: Medical Records and Health Information

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This page explains English vocabulary for learners. It is not medical advice.