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A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
The main discussion of these abbreviations in the context of drug prescriptions and other medical prescriptions is at List of abbreviations used in medical prescriptions. Some of these abbreviations are best not used, as marked and explained here.
The assessment and plan (abbreviated A/P" [1] or A&P) is a component of an admission note. Assessment includes a discussion of the differential diagnosis and supporting history and exam findings. The plan is typically broken out by problem or system. Each problem should include: brief summary of the problem, perhaps including what has been done ...
An objective structured clinical examination (OSCE) is an approach to the assessment of clinical competence in which the components are assessed in a planned or structured way with attention being paid to the objectivity of the examination which is basically an organization framework consisting of multiple stations around which students rotate and at which students perform and are assessed on ...
This is a list of roots, suffixes, and prefixes used in medical terminology, their meanings, and their etymologies. Most of them are combining forms in Neo-Latin and hence international scientific vocabulary. There are a few general rules about how they combine.
Medical terminology is a language used to precisely describe the human body including all its components, processes, conditions affecting it, and procedures performed upon it. Medical terminology is used in the field of medicine .
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).