TERMIUM Plus®

The Government of Canada’s terminology and linguistic data bank.

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Record 1 2016-08-29

English

Subject field(s)
  • Medical and Hospital Organization
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.

French

Domaine(s)
  • Organisation médico-hospitalière
DEF

[...] ensemble des pièces (fiche signalétique du malade, fiches d'observation du médecin, radiographies, ordonnances, analyses, etc.) relatives à un malade [...]

Spanish

Campo(s) temático(s)
  • Organización médica y hospitalaria
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.

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