TERMIUM Plus®
The Government of Canada’s terminology and linguistic data bank.
expediente clínico [2 records]
Record 1 - internal organization data 2016-08-29
Record 1, English
Record 1, Subject field(s)
- Medical and Hospital Organization
Record 1, Main entry term, English
- medical record
1, record 1, English, medical%20record
correct
Record 1, Abbreviations, English
Record 1, Synonyms, English
- health file 2, record 1, English, health%20file
correct
- patient's chart 3, record 1, English, patient%27s%20chart
correct
- medical chart 4, record 1, English, medical%20chart
correct
- chart 5, record 1, English, chart
correct, noun
- patient file 6, record 1, English, patient%20file
correct
- medical file 6, record 1, English, medical%20file
correct
Record 1, Textual support, English
Record number: 1, Textual support number: 1 DEF
... a written document containing (1) the medical history, (2) the findings from the physical examination, (3) the reports of laboratory tests, (4) the findings and conclusions from special examinations, (5) the findings and diagnoses of consultants, (6) the diagnoses of the responsible physician, (7) notes on treatment ..., and (8) progress notes by physicians, nurses and others. 7, record 1, English, - medical%20record
Record 1, French
Record 1, Domaine(s)
- Organisation médico-hospitalière
Record 1, Main entry term, French
- dossier médical
1, record 1, French, dossier%20m%C3%A9dical
correct, masculine noun
Record 1, Abbreviations, French
Record 1, Synonyms, French
- dossier du patient 2, record 1, French, dossier%20du%20patient
correct, masculine noun
- observation 3, record 1, French, observation
correct, feminine noun, France
Record 1, Textual support, French
Record number: 1, Textual support number: 1 DEF
[...] ensemble des pièces (fiche signalétique du malade, fiches d'observation du médecin, radiographies, ordonnances, analyses, etc.) relatives à un malade [...] 4, record 1, French, - dossier%20m%C3%A9dical
Record 1, Spanish
Record 1, Campo(s) temático(s)
- Organización médica y hospitalaria
Record 1, Main entry term, Spanish
- expediente clínico
1, record 1, Spanish, expediente%20cl%C3%ADnico
correct, masculine noun
Record 1, Abbreviations, Spanish
Record 1, Synonyms, Spanish
- expediente médico 2, record 1, Spanish, expediente%20m%C3%A9dico
correct, masculine noun
Record 1, Textual support, Spanish
Record number: 1, Textual support number: 1 DEF
Conjunto de documentos básicos escritos de manera específica, exacta y ordenada, que reflejan con claridad el historial de salud de un paciente; por lo tanto, comprende el registro de hechos demográficos vitales y de morbilidad, tratamientos impartidos y resultados obtenidos. 1, record 1, Spanish, - expediente%20cl%C3%ADnico
Record 2 - internal organization data 2010-05-21
Record 2, English
Record 2, Subject field(s)
- Medical and Hospital Organization
- Medical and Dental Services (Military)
Record 2, Main entry term, English
- health record 1, record 2, English, health%20record
Record 2, Abbreviations, English
- Hlth Rcd 2, record 2, English, Hlth%20Rcd
Record 2, Synonyms, English
Record 2, Textual support, English
Record number: 2, Textual support number: 1 OBS
Hlth Rcd: abbreviation used by the Department of National Defence. 2, record 2, English, - health%20record
Record 2, French
Record 2, Domaine(s)
- Organisation médico-hospitalière
- Service de santé et service dentaire (Militaire)
Record 2, Main entry term, French
- dossier médical
1, record 2, French, dossier%20m%C3%A9dical
masculine noun
Record 2, Abbreviations, French
- DM 1, record 2, French, DM
masculine noun
Record 2, Synonyms, French
- dossier de santé 2, record 2, French, dossier%20de%20sant%C3%A9
masculine noun
Record 2, Textual support, French
Record 2, Spanish
Record 2, Campo(s) temático(s)
- Organización médica y hospitalaria
- Servicios médico y dental (Militar)
Record 2, Main entry term, Spanish
- historia clínica
1, record 2, Spanish, historia%20cl%C3%ADnica
correct, feminine noun
Record 2, Abbreviations, Spanish
Record 2, Synonyms, Spanish
- expediente clínico 2, record 2, Spanish, expediente%20cl%C3%ADnico
correct, masculine noun
- historial médico 3, record 2, Spanish, historial%20m%C3%A9dico
correct, masculine noun
- historial clínico 3, record 2, Spanish, historial%20cl%C3%ADnico
correct, masculine noun
Record 2, Textual support, Spanish
Record number: 2, Textual support number: 1 DEF
Documento privado, personal, que posee determinadas características éticas, legales, docentes, estadísticas y médicas; [es un] registro de datos médicos sobre el diagnóstico, terapia y evolución de la enfermedad del paciente; [...] también recoge la opinión del profesional sobre la evolución de la enfermedad, las opiniones de otros facultativos cuando existen inter-consultas o los cambios de terapia según las evaluaciones que realice el titular. 2, record 2, Spanish, - historia%20cl%C3%ADnica
Record number: 2, Textual support number: 1 CONT
La asistencia a los pacientes tanto hospitalizados como ambulatorios genera una serie de información médica y administrativa sobre los mismos. Dicha información se registra en varios documentos, siendo el conjunto de estos documentos lo que constituye la historia clínica. La historia clínica debe ser única, integrada y acumulativa para cada paciente en el hospital, debiendo existir un sistema eficaz de recuperación de la información clínica. 4, record 2, Spanish, - historia%20cl%C3%ADnica
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