GC: n

S: http://www.health.ny.gov/publications/0213.pdf (last access: Marcfh 2013); HHS – http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/medicalrecords.html (last access: 29 July 2015).

N: – medical (adj): “pertaining or relating to the art or profession of healing or those who practice it,” 1640s, from French médical, from Late Latin medicalis “of a physician,” from Latin medicus “physician, surgeon, medical man” (n.); “healing, medicinal” (adj.), from medeor “to cure, heal,” originally “know the best course for,” from an early specialization of PIE root *med- “take appropriate measures” (source also of Avestan vi-mad- “physician”). “The meaning of medeor is based on a semantic shift from ‘measure’ to ‘distribute a cure, heal'” (de Vaan). The earlier adjective in English in this sense was medicinal. Related: Medically.
– record (n): c. 1300, “testimony committed to writing,” from Old French record “memory, statement, report,” from recorder “to record” (see record (v.)). Meaning “written account of some event” is from late 14c. Meaning “disk on which sounds or images have been recorded” is first attested 1878. That of “best or highest recorded achievement in sports, etc.” is from 1883. Phrase on the record is from 1900; adverbial phrase off the record “confidentially” is attested from 1906. Record-player attested from 1919.
2. In medicine or dentistry, a chronologic written account that includes a patient’s initial complaint(s) and medical history, physical findings, results of diagnostic tests and procedures, any therapeutic medicines or procedures, and subsequent developments during the course of the illness.
3. In dentistry, a registration of desired jaw relations in a plastic material or on a device to permit these relationships to be transferred to an articulator.

S: 1. OED – https://www.etymonline.com/search?q=medical+record (last access: 30 October 2019). 2 & 3. http://medical-dictionary.thefreedictionary.com/medical+record (last access: 29 July 2015).

SYN: case history, clinical chart, clinical notes, clinical record, health record, medical notes, medical file, patient chart, patient file, patient’s notes, patient record. (depending on context)

S: COSNAUTAS (last access: 29 July 2015)

CR: anamnesis, medical history.