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The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
Progress Notes are 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. [1]
Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care.
The method by which doctors gather information about a patient's past and present medical condition in order to make informed clinical decisions is called the history and physical (a.k.a. the H&P). The history requires that a clinician be skilled in asking appropriate and relevant questions that can provide them with some insight as to what the ...
H&P: history and physical examination (which very often are considered as a pair) HPA: hypothalamic-pituitary-adrenal axis: HPETE: hydroxyeicosatetraenoic acid: HPF: high-power field HPI H/oPI: history of the present illness: HPOA: hypertrophic pulmonary osteoarthropathy hPL: human placental lactogen (same as human chorionic somatomammotropin) HPP
This template is used on many pages and changes may be widely noticed. Test changes in the template's /sandbox or /testcases subpages, or in your own user subpage . Consider discussing changes on the talk page before implementing them.
Risk and Safety Statements, also known as R/S statements, R/S numbers, R/S phrases, and R/S sentences, is a system of hazard codes and phrases for labeling dangerous chemicals and compounds.