When going to a physician he used to write what the complaint of the patient is, on a paper. He also used to write his findings in physical examination, observation, diagnosis, recommendations, etc. on this paper. What is this document called?

By googling I found "patient medical history", or "patient medical history" but I'm not sure if this is what I'm looking for. I looked for a translation in my language but I didn't find.

1 Answer 1


The word you are looking for is


All observations, notes and instructions are kept in your medical charts, and these are the clipboards and binders that used to hang off the end of the patient's bed, but now are mainly kept on computers.

Over time the collection of charts become your medical records.

  • Thank you. I think the term that I looked for was indeed medical record. The one the person gets after being in an hospital. It includes chief complains, tests, physical examination, diagnosis, treatment and further recommendations. en.wikipedia.org/wiki/Medical_record Apr 1, 2018 at 21:04

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