notas de la historia clínica
/notas de la istoɾja klinika/from spelling rules
The English phrase 'chart notes' is translated into Spanish as notas de la historia clínica.
This phrase is used in medical and administrative contexts to refer to the documentation within a patient's medical record.
What does it mean word for word?
Literally, the phrase translates to 'notes of the clinical history'.
Which one should you use?
While notas refers to the specific notes, historia clínica is the standard term for the entire medical record or patient chart itself.
Did you know?
- In some Spanish-speaking countries, a physician might refer to the 'chart notes' as evoluciones. This term focuses on how the patient's condition is evolving over time rather than just the record itself.
- In many Spanish-speaking healthcare systems, the historia clínica is legally considered a shared document between the doctor and the patient, giving the patient a stronger legal right to access the 'chart notes' than in some English-speaking systems.
- The word clínica in historia clínica is a learned borrowing from the Latin clīnicē, which traces its ultimate origins back to the Ancient Greek word for 'bedside'.
Examples in context
- Estoy tomando notas de la historia clínica.I am taking chart notes.
- El médico completó las notas de la historia clínica del paciente.The doctor completed the chart notes of the patient.
- Las enfermeras están revisando los apuntes del expediente médico antes de comenzar la cirugía.The nurses are reviewing the chart notes before starting the surgery.
- Necesito revisar las notas de la historia clínica.I need to review the chart notes.
- Las notas de la historia clínica están incompletas.The chart notes are incomplete.
- El doctor actualizó las notas de la historia clínica.The doctor updated the chart notes.
Example conversation
A doctor and a nurse are discussing a patient's file in a hospital.
- Daniel¿Has leído las notas de la historia clínica?Have you read the chart notes?
- LucíaSí, Daniel, las acabo de leer.Yes, Daniel, I just read them.
- DanielPerfecto, Lucía, entonces podemos proceder.Perfect, Lucía, then we can proceed.
- LucíaDe acuerdo, voy a preparar todo.Agreed, I am going to prepare everything.
Sources
- IPA marked “from spelling rules” is derived from standard Spanish spelling, where Wiktionary gives none.
- Word origins: Wiktionary entries clínica, de, historia, la, CC BY-SA 4.0.
