patient record

[/ˈpeɪʃənt ˈrekərd/]
nounpl: patient records
prontuário do paciente
1. A comprehensive document containing all medical information about a patient, including medical history, diagnoses, treatments, medications, test results, and clinical notes
The doctor reviewed the patient record before the appointment.
O médico revisou o prontuário do paciente antes da consulta.
2. An official medical file maintained by a healthcare provider or institution for continuity of care and legal documentation
Patient records must be kept confidential according to HIPAA regulations.
Os prontuários dos pacientes devem ser mantidos confidenciais de acordo com as regulações HIPAA.
3. A digital or physical archive containing all healthcare encounters and medical data for a specific individual
Electronic patient records have improved the efficiency of healthcare delivery.
Os prontuários eletrônicos do paciente melhoraram a eficiência da prestação de cuidados de saúde.
In Brazil, patient records (prontuários) are essential components of the healthcare system managed by public (SUS) and private institutions. LGPD (Lei Geral de Proteção de Dados) has strengthened privacy protections. In the USA, patient records are strictly regulated under HIPAA, and the shift to electronic health records (EHRs) has been a major healthcare initiative since the 2000s. Access and data security are critical concerns in both countries.
Synonyms / Sinônimos
medical recordhealth recordclinical recordmedical filecase history

Regional Variations

General Brazilian
prontuário do paciente
Most common term used in healthcare settings throughout Brazil
Rio de Janeiro
prontuário médico
Alternative form emphasizing medical aspect
São Paulo
registro de saúde do paciente
More formal alternative used in some institutions
Portugal
processo clínico
Portuguese European term for patient medical file

Related Words

electronic health record (EHR)medical historyclinical notesdiagnosisprescriptionmedical documentation

Related Idioms & Phrases

on the record - formally documented
off the record - not officially documented
keep a record - maintain documentation
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