Medical Records

Grammar resources

Vocabulary List

Administrative Officer
Administrative officers oversee and implement administrative procedures, establish work priorities and co-ordinate the acquisition of administrative services such as office space, supplies and security services.
Ambulatory care
A personal health care consultation, treatment, or intervention using advanced medical technology or procedures delivered on an outpatient basis
Canada Health Infoway
A strategic investor, they work with Canadian provinces and territories with the goal of creating an electronic health record for 50% of Canadians
Coding diseases (International Classification of Diseases)
The standard diagnostic tool for epidemiology, health management and clinical purposes.This includes the analysis of the general health situation of population groups. It is used to monitor the incidence and prevalence of diseases and other health problems.
general purpose device that can be programmed to carry out a set of arithmetic or logical operations.
A set of rules or a promise that limits access or places restrictions on certain types of information. 
agreement or permission to do or allow something
Agreement or permission to do or allow something.
a government official who confirms and certifies the death of an individual within a jurisdiction
A government official who confirms and certifies the death of an individual within a jurisdiction.
(also court of law) a body of people presided over by a judge, judges, or magistrate, and acting as a tribunal in civil and criminal cases
A judicial tribunal duly constituted for the hearing and determination of cases.
Data collection
The process of gathering and measuring information on variables of interest, in an established systematic fashion that enables one to answer stated research questions, test hypotheses, and evaluate outcomes
identification of the nature and cause of a certain phenomenon.
A symptom or characteristic of value in diagnosis.
The release of information about a person or entity.
abnormal condition that affects the body of an organism. It is often construed as a medical condition associated with specific symptoms and signs
A person, especially a physician, dentist, or veterinarian, trained in the healing arts and licensed to practice.
substance which may have medicinal, intoxicating, performance enhancing or other effects when taken or put into a human body or the body of another animal and is not considered a food or exclusively a food
The study of the patterns, causes, and effects of health and disease conditions in defined populations.
fax machine
telephonic transmission of scanned printed material (both text and images), normally to a telephone number connected to a printer or other output device
kind of folder that holds loose papers together for organization and protection
Files users
A collection of papers, records of users arranged in convenient order
printed document with blank spaces for information to be inserted
level of functional or metabolic efficiency of a living organism
health care institution providing patient treatment by specialized staff and equipment.
The act, process, or state of being hospitalized
knowledge that you get about someone or something
Information Management
The collection and management of information from one or more sources and the distribution of that information to one or more audiences.
The study and theory of law
medical coding
rocess of transforming descriptions of medical diagnoses and procedures into universal medical code numbers
Medical record
The systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction
Medical Terminology
An important foundation for any healthcare employee
Medical transcription
An allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physiciansor other healthcare professionals, into text format.
field of applied science related to the art of healing by diagnosis, treatment, and prevention of disease.
Normative framework
The term "normative" is used to describe the way something ought to be done according to a value position
a room or other area where administrative work is done, but may also denote a position within an organization with specific duties attached to it (see officer, office-holder, official); the latter is in fact an earlier usage, office as place originally referring to the location of one's duty
office chair
type of chair that is designed for use at a desk in an office.
is any recipient of health care services. The patient is most often ill or injured and in need of treatment by a physician, physician assistant, advanced practice registered nurse, veterinarian, or other health care provider.
Machine that makes paper copies of documents and other visual images quickly and cheaply
ystematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction
retention schedule
A document listing all the titles of the records series, length of time each document or record will be retained as an active record, the reason for its retention and disposition agreed by the user, receiver, and Records Director and Records Retention committee.
a person’s name written in a distinctive way as a form of identification in authorizing a cheque or document or concluding a letter:
on-tangible component of computers. Computer software contrasts with computer hardware, which is the physical component of computers. Computer hardware and software require each other and neither can be realistically used without the other
study of the collection, organization, analysis, interpretation and presentation of data
The study of the collection, organization, analysis, interpretation and presentation of data.
Striking off
To remove or erase from a list, record the patient has left the hospital
A document that requires its recipient to appear in court as a witness
The delivery of health-related services and information via telecommunications technologies
telecommunications device that permits two or more users to conduct a conversation when they are not in the same vicinity of each other to be heard directly
Trauma registry
A trauma registry is a system of timely data collection that aids in the evaluation of trauma care for a set of injured patients who meet specific criteria for inclusion.