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  2. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    It provides information for the continuation of care following discharge. [10] History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. [11] Operative Note - The Operative Note is created immediately following a surgical or other high-risk procedure.

  3. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.

  4. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR. [2] Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5]

  5. Medication package insert - Wikipedia

    en.wikipedia.org/wiki/Medication_package_insert

    PILLS (Patient Information Language Localisation System) is a one-year effort by the European Commission to produce a prototype tool which will support the creation of various kinds of medical documentation simultaneously in multiple languages, by storing the information in a database and allowing a variety of forms and languages of output.

  6. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.

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  8. Template:Medical resources - Wikipedia

    en.wikipedia.org/wiki/Template:Medical_resources

    External links to medical information Template parameters [Edit template data] This template prefers block formatting of parameters. Parameter Description Type Status QID QID Wikidata number Unknown suggested ICD11 ICD11 no description Unknown optional ICD10 ICD10 Note: ICD-10-CM has a separate parameter Unknown suggested ICD10CM ICD10CM no description Unknown optional ICD9 ICD9 no description ...

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