Definitions for "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.
A single, complete record kept at the site of the client's primary care provider that documents the medical services received by the client, including inpatient discharge summary, outpatient and emergency care.
the case history of a medical patient