I have been studying Medical Records Management since 2021. I would like to introduce to you terms on my fields of study. If you are interested in, this glossary will be useful. It's also helpful for my future job.
ambulatory care
noun
A personal health care consultation, treatment, or intervention using advanced medical technology or procedures delivered on an outpatient basis.
Example: Emergency and ambulatory care is one of the largest-volume patient activities in the country, making it a key component of the continuum of health services in Canada.
en: soins ambulatoires
Anatomical pathology
noun
The study of organs and tissues to determine the causes and effects of particular diseases.
Example: Anatomical pathologists specialize in examining tissues removed by needle aspiration, surgical procedures or autopsy.
en: anatomopathologie
anesthetist
noun
A medical specialist who gives anesthesia, esp. during an operation.
Example: On the other hand, in the case of electrocardiograms, the most commonly used criterion was age (78% of surgeons and 76% of anesthetists).
en: anesthésiste
biopsy
noun
The process of removing and examining a small amount of tissue from a sick person, in order to discover more about their illness.
Example: The diagnosis of cirrhosis was based on liver biopsy or conventional clinical, biological and endoscopic findings.
en: biopsie
cancer
noun
A serious disease that is caused when cells in the body grow in a way that is uncontrolled and not normal, killing normal cells and often causing death.
Example: Cancer that spreads to a secondary site is considered advanced or metastatic.
en: cancer
confidentiality
noun
A set of rules or a promise that limits access or places restrictions on certain types of information.
Example: As a general rule, medical records of patients are confidential.
en: confidentialité
diagnosis
noun
The decision reached from such an examination.
Example: His doctor made an initial diagnosis of pneumonia.
en: diagnostic
discharge summary
noun
A clinical report prepared by a health professional outlining the patient’s chief complaint, the diagnostic findings, the therapy administered and the patient’s response to it, and recommendations on discharge.
Example: West Midlands Ambulance Service (WMAS) has apologised for the ‘distress’ caused to a deceased patient’s GP after a discharge summary blamed general practice for ‘causing problems’.
en: feuille sommaire
endoscopy
noun
A procedure that uses an endoscope to look inside the body to examine or treat organs or structures.
Example: An upper endoscopy, also called an upper gastrointestinal endoscopy, is a procedure used to visually examine your upper digestive system.
en: endoscopie
Epidemiology
noun
The study of the patterns, causes, and effects of health and disease conditions in defined populations.
Example: In epidemiology, the patient is the community and individuals are viewed collectively.
en: Épidémiologie
hospital
noun
A health care institution providing patient treatment by specialized staff and equipment.
Example: You can fill out the form in person during the business hours of the hospital's Access to Health Information Office where you received health care.
en: hôpital
hospitalization
noun
The act of taking someone to hospital and keeping them there for treatment.
Example: Because of the severity of the accident, the patient required hospitalization.
en: hospitalisation
International Classification of Diseases
noun
The standard diagnostic tool for epidemiology, health management and clinical purposes, used to monitor the incidence and prevalence of diseases and other health problems.
Example: For more than a century, the International Classification of Diseases (ICD) has been the basis for comparable statistics on causes of mortality and morbidity between places and over time.
en: Classification internationale des maladies
medical coding
noun
The process of transforming descriptions of medical diagnoses and procedures into universal medical
code numbers.
Example: Today, the medical coding market is highly complex, with more than 68,000 diagnostic codes and over 10,000 Current Procedural Terminology (CPT) codes.
en: codage médical
medical record
noun
A chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the physician's physical findings, the results of diagnostic tests and procedures, and medications and therapeutic procedures.
Example: The medical record contributes to the quality, continuity and assessment of patient care.
en: Dossier médical
patient
noun
Any recipient of health care services, who is ill or injured and in need of treatment by a medical professional.
Example: The patient had surgery on his heart.
en: patient
progress notes
noun
The part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care.
Example: Progress Notes lets you quickly and easily document key patient information in a single note shared across your team.
en: notes d'évolution
surgeon
noun
A medical specialist who practices surgery.
Example: Your surgeon needs to know your health history so that they can take good care of you.
en: chirurgien, chirurgienne
trauma registry
noun
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.
Example: Do we need to submit patients with isolated burns to the burn registry and the trauma registry?
en: registre des traumatismes
tumor
noun
A mass of diseased cells that might become a lump or cause illness.
Example: They found a malignant tumor in her breast.
