TERMIUM Plus®
The Government of Canada’s terminology and linguistic data bank.
HISTORIAL MEDICO [2 records]
Record 1 - internal organization data 2011-12-21
Record 1, English
Record 1, Subject field(s)
- Medical and Hospital Organization
Record 1, Main entry term, English
- hospital discharge report
1, record 1, English, hospital%20discharge%20report
correct
Record 1, Abbreviations, English
Record 1, Synonyms, English
Record 1, Textual support, English
Record 1, French
Record 1, Domaine(s)
- Organisation médico-hospitalière
Record 1, Main entry term, French
- rapport médical de sortie
1, record 1, French, rapport%20m%C3%A9dical%20de%20sortie
correct, masculine noun
Record 1, Abbreviations, French
Record 1, Synonyms, French
- rapport de sortie d'hôpital 2, record 1, French, rapport%20de%20sortie%20d%27h%C3%B4pital
correct, masculine noun
Record 1, Textual support, French
Record number: 1, Textual support number: 1 CONT
Critères de sortie des patients hospitalisés. Les critères de sortie sont définis dans l’aide-mémoire. Ils se basent sur les directives de pandémie canadiennes et anglaises. En fonction de la situation d’occupation des lits, il faudra adapter ces critères. [...] Afin de simplifier les tâches administratives, les rapports au médecin prenant la suite du traitement ont lieu sous la forme d’un rapport médical de sortie standardisé, aussi bien pour les patients ambulatoires qu’hospitalisés. 1, record 1, French, - rapport%20m%C3%A9dical%20de%20sortie
Record 1, Spanish
Record 1, Campo(s) temático(s)
- Organización médica y hospitalaria
Record 1, Main entry term, Spanish
- informe de alta médica
1, record 1, Spanish, informe%20de%20alta%20m%C3%A9dica
correct, masculine noun
Record 1, Abbreviations, Spanish
Record 1, Synonyms, Spanish
- informe de alta médica hospitalaria 2, record 1, Spanish, informe%20de%20alta%20m%C3%A9dica%20hospitalaria
correct, masculine noun
Record 1, Textual support, Spanish
Record number: 1, Textual support number: 1 DEF
Documento emitido por el médico responsable en un centro sanitario al finalizar cada proceso asistencial de un paciente, que especifica los datos de éste, un resumen de su historial clínico, la actividad asistencial prestada, el diagnóstico y las recomendaciones terapéuticas. 1, record 1, Spanish, - informe%20de%20alta%20m%C3%A9dica
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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