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Definition

record

(rek'ŏrd )

  1. A written account of something.

    SEE: problem-oriented medical record.

  2. In dentistry, a registration of jaw relations in a malleable material or on a device.

anecdotal r.Notes used in nursing education to document observed incidents of a student's clinical behavior related to attainment of clinical learning objectives. Such anecdotal notes have not been treated as hearsay evidence in a court but have been upheld as documented evidence for failing a student.

electronic health r.

ABBR: EHR

Electronic medical record.

electronic medical r.

ABBR: EMR

A computerized database that typically includes demographic, past medical and surgical, preventive, laboratory and radiographic, and drug information about a patient. It is the repository for active notations about a patient's health. Most EMRs also contain billing and insurance information and other accounting tools. SYN: electronic health record.

functional chew-in r.A record of the natural chewing action of the mand ible made on an occlusion rim by the teeth or scribing studs.

interocclusal r.Bite plate.

medical r.A transcript of information obtained from a patient, guardian, or medical professionals concerning a patient's health history, diagnostic tests, diagnoses, treatment, and prognosis.

medication administration r.

ABBR: MAR

A file maintained on hospital units that documents the schedule and dosing of medications given to patients.

open medical r.A medical record accessible to the patient for his or her personal review and to others authorized by the patient.

personal health r.A summary of a patient's health care status (allergies, drugs taken, past hospitalizations, lab tests, radiology results, and surgeries) that is kept by the patient privately rather than stored in a hospital or third-party database.