CLINICAL RECORD Meaning and
Definition
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A clinical record refers to a comprehensive and systematic documentation of medical information pertaining to a patient's health history, diagnosis, treatment, and care provided by healthcare professionals. It serves as a crucial and legal record of the patient's journey through the healthcare system, covering both inpatient and outpatient settings. Clinical records are typically created and maintained by healthcare providers, including physicians, nurses, and other clinicians involved in the patient's care.
The content within a clinical record typically includes personal and demographic information, medical history, laboratory results, diagnostic tests, progress notes, treatment plans, medications prescribed, allergies, immunization records, radiology reports, and any other relevant medical documentation. This compilation of data facilitates communication and ensures continuity of care among healthcare professionals involved in the patient's treatment.
Clinical records play an instrumental role in healthcare delivery, enabling healthcare providers to make informed decisions, track patient progress over time, and provide evidence-based care. These records also serve as crucial tools for medical research, quality assurance, and legal documentation. Maintaining accurate and complete clinical records is vital for ensuring patient safety, promoting effective care coordination, and adhering to ethical and legal standards.
As healthcare continues to advance, clinical records are increasingly transitioning from traditional paper formats to electronic health records (EHRs) for improved accessibility, efficiency, and data exchange. EHRs aim to streamline healthcare processes, enhance patient outcomes, and enable data-driven decision-making while maintaining confidentiality and security.
Common Misspellings for CLINICAL RECORD
- xlinical record
- vlinical record
- flinical record
- dlinical record
- ckinical record
- cpinical record
- coinical record
- clunical record
- cljnical record
- clknical record
- clonical record
- cl9nical record
- cl8nical record
- clibical record
- climical record
- clijical record
- clihical record
- clinucal record
- clinjcal record
- clinkcal record
Etymology of CLINICAL RECORD
The term "clinical record" is composed of two words: "clinical" and "record".
The word "clinical" originates from the Latin word "clinicus", which means pertaining to a bed or a person in bed. In medieval Latin, it evolved to "clinicum", referring to the bedchamber or sickroom. From there, it entered Old French as "clinique" and then entered English in the late 16th century.
The word "record" comes from the Old French "recorde", derived from the Latin word "recordari", meaning to call back, remember, or remind. In Old English, the word was "ge recordian". Over time, "record" developed meanings related to writing things down or keeping a written account.
