Medical Records Glossary

20 Medical Record terms

Hi, my name is Daryll Dorcely. I live in Montreal. I have been studying Medical Records for 2 years at Ahuntsic College. I made a glossary about my field of study for those who are interested in Medical Records or to help those in the same field as mine. Each word in my glossary are there to help people understand the Medical Records field.

active records
noun
Active records are documents which are still actively being used by an office. They are usually referenced on a daily or monthly basis. Often times, if in paper, these records will be located in a handy place within the office since they are used frequently.
fr: dossiers actifs
alphanumeric order
noun
Alphanumeric order refers to a set of filing rules to follow when putting symbols, numbers and letters in order both numerically and alphabetically
fr: ordre alphanumérique
ambulatory care
noun
Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and procedures even when provided outside of hospitals.
Example: Ambulatory care refers to medical services performed on an outpatient basis, without admission to a hospital or other facility.
fr: soins ambulatoires
appraisal
noun
A detailed evaluation a property's value that is typically conducted by a professional.
Example: In what comprises the first extended appraisal of Maxentius' architecture and patronage, I present new restorations of these monuments with especial attention to their architectural design.
fr: évaluation
archives
noun
An archive is an accumulation of historical records or the physical place they are located. Archives contain primary source documents that have accumulated over the course of an individual or organization's lifetime, and are kept to show the function of that person or organization.
Example: Though her convent no longer exists in its original location, examination of the documents held in the archives of la Crocetta, the State archives of Florence, and the Ospedale degli Innocenti in Florence has allowed for a reconstruction of the process by which Suor Domenica was able to build her convent.
fr: archives
archivist
noun
An archivist appraises and researches records and documents to determine their importance and potential value. She then preserves and catalogs these materials so people can access them in the future, ensuring they're not lost and forgotten. ... An archivist can also provide outreach to the public
fr: archiviste
chronological
noun
Chronological order refers to ordering events in accordance with the time sequence in which they occurred, ie an event that occurred in 1912 would be list d after an event that occurred in 1911 but before an event that occurred in 1913.
Example: Its main chronological narrative traces the process by which younger members of the Federalist elite, frustrated with post-war developments that prevented them from claiming political and social power, came to remake the town in an English- influenced style and why other stylistic influences (especially those from France) were de-emphasized.
fr: chronologique
computer
noun
A computer is a machine or device that performs processes, calculations and operations based on instructions provided by a software or hardware program. It is designed to execute applications and provides a variety of solutions by combining integrated hardware and software components.
Example: I show how the computer contributed to the collapse of functionalism and to the development of a new approach to architectural design that was based on the sequential use of transformational operations such as duplication, rotation, scaling, and skewing.
fr: ordinateur
computer output microfilm
noun
Computer Output Microfilm (COM) is a system that converts stored data directly to microfilm or microfiche
fr: microfilm de sortie informatique
confidentiality
noun
adjective. spoken, written, acted on, etc., in strict privacy or secrecy; secret: a confidential remark. ... having another's trust or confidence; entrusted with secrets or private affairs: a confidential secretary.
Example: the principle of confidentiality or plain secrecy in key areas.
fr: confidentialité
consent
noun
to permit, approve, or agree; comply or yield (often followed by to or an infinitive): He consented to the proposal. ... Archaic. to agree in sentiment, opinion, etc.; be in harmony.
fr: consentement
coroner
noun
a usually elected public officer who is typically not required to have specific medical qualifications and whose principal duty is to inquire by an inquest into the cause of any death which there is reason to suppose is not due to natural causes — compare medical examiner
Example: Mr Daniel Williams, the coroner at the inquest at Honiton, said Joanna Burrell, aged 15, could not cope with her physical sexual experiences "divorced from any continuing permanent affection".
fr: coroner
court
noun
A court is any person or institution with authority to judge or adjudicate, often as a government institution, with the authority to adjudicate legal disputes between parties and carry out the administration of justice in civil, criminal, and administrative matters in accordance with the rule of law.
Example: Kiernan reports suggestions that Lermontov's own death (like Pushkin's in another duel a few months before) may have been murder, a murder planned by court reactionaries.
fr: tribunal
custody
noun
uncountable noun. Custody is the legal right to keep and look after a child, especially the right given to a child's mother or father when they get divorced. I'm going to go to court to get custody of the children. [ + of] Child custody is normally granted to the mother.
Example: All three were related to Ashraf Said, a suspect in the Khan Al-Khalili bazaar blast who died in police custody.
fr: garde
diagnosis
noun
Medical diagnosis (abbreviated Dx or DS) is the process of determining which disease or condition explains a person's symptoms and signs. ... Often, one or more diagnostic procedures, such as medical tests, are also done during the process.
Example: Anxiety is an important issue in cancer care and is often associated with a cancer diagnosis and the subsequent oncology treatment process (Skeel, 1999).
fr: diagnostic
doctor
noun
A doctor is someone who is qualified in medicine and treats people who are ill. ... A doctor is someone who has been awarded the highest academic or honorary degree by a university.
fr: médecin
drug
noun
A drug is a chemical which is given to people in order to treat or prevent an illness or disease. ... Drugs are substances that some people take because of their pleasant effects, but which are usually illegal.
Example: I quote from its fact - sheet: "The ultimate aim is to provide alternative methods for use in toxicity testing and in drug development, which will be so relevant and reliable that no animal testing will be necessary., But, it must be stressed, this is not a call for the total abolition of animals from the research laboratory.
fr: drogue
duplicate
noun
exactly like or corresponding to something else: duplicate copies of a letter. consisting of or existing in two identical or corresponding parts; double.
Example: In museum culture the original physical artefact is venerated at the expense of a replica, duplicate, reconstruction, or hologram.
fr: dupliquer
epidemiology
noun
Epidemiology is the study of diseases in populations of humans or other animals, specifically how, when and where they occur
Example: This concentration upon identifying broad trends in the epidemiology or organic brain disorders is reflected in the sections of this chapter dealing with incidence and prevalence.
fr: épidémiologie
medical coding
noun
After graduating from high school, aspiring medical coders have three main options for their undergraduate education: a certificate program, an associate's degree, or a bachelor's degree. A certificate program is the quickest route to working in the field, as most take less than a year to complete.
fr: codage médical