clinical record
[ˈklɪnɪkəl ˈrekɔːrd]
nounpl: clinical records
prontuário clínico
1. A comprehensive written or electronic documentation of a patient's medical history, symptoms, diagnoses, treatments, and clinical observations maintained by healthcare providers
The clinical record shows that the patient was diagnosed with hypertension three years ago.
O prontuário clínico mostra que o paciente foi diagnosticado com hipertensão há três anos.
2. An official medical document containing all health-related information about a patient's interactions with healthcare facilities
A complete clinical record is essential for continuity of care when patients switch doctors.
Um prontuário clínico completo é essencial para a continuidade do cuidado quando os pacientes mudam de médico.
In Brazil, clinical records (prontuários clínicos) are legally required documents in all healthcare settings and are subject to patient confidentiality laws. The digitalization of clinical records through electronic health record systems (prontuários eletrônicos) is increasingly mandated by healthcare regulations in Brazil. In the USA, clinical records are protected under HIPAA (Health Insurance Portability and Accountability Act), and patients have the right to access their own records.
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