clinical notes
[ˈklɪnɪkəl noʊts]
nounpl: clinical notes
notas clínicas
1. Written records documenting a patient's medical history, symptoms, examination findings, diagnoses, and treatment plans made by healthcare professionals during or after patient care
The doctor reviewed the clinical notes from the patient's previous hospital visit before starting treatment.
O médico revisou as notas clínicas da internação anterior do paciente antes de iniciar o tratamento.
2. Detailed observations and records maintained in a patient's medical file for continuity of care and legal documentation
Accurate clinical notes are essential for ensuring proper follow-up care and protecting healthcare providers legally.
As notas clínicas precisas são essenciais para garantir o acompanhamento adequado do paciente e proteger os profissionais de saúde legalmente.
Clinical notes are a critical component of healthcare documentation in both Brazil and the United States. In Brazil, healthcare institutions are required by law (LGPD - Lei Geral de Proteção de Dados) to maintain secure and accurate clinical notes. In the USA, these notes are protected under HIPAA regulations. Both countries emphasize the importance of thorough documentation for patient safety, continuity of care, and legal protection. Electronic clinical notes have become increasingly standard in both countries.
Related Idioms & Phrases
keep detailed clinical notes
chart review clinical notes
clinical notes for the record
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