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  2. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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 ...

  3. Medical certificate - Wikipedia

    en.wikipedia.org/wiki/Medical_certificate

    A medical certificate or doctor's certificate [1] [2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [3] It can serve as a sick note (UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition. [4]

  4. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase such as "no family h/o of heart or lung problems" may be used to specifically indicate that questions about a system were asked. social history (SH) "Denies x3"

  5. List of medical tests - Wikipedia

    en.wikipedia.org/wiki/List_of_medical_tests

    The tests are classified by speciality field, conveying in which ward of a hospital or by which specialist doctor these tests are usually performed. The ICD-10-CM is generally the most widely used standard by insurance companies and hospitals who have to communicate with one another, for giving a overview of medical tests and procedures. It has ...

  6. OPQRST - Wikipedia

    en.wikipedia.org/wiki/OPQRST

    Each letter stands for an important line of questioning for the patient assessment. [ 3 ] [ 4 ] This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of a SOAP note , for later reference.

  7. SAMPLE history - Wikipedia

    en.wikipedia.org/wiki/SAMPLE_History

    It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]

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  9. List of abbreviations for diseases and disorders - Wikipedia

    en.wikipedia.org/wiki/List_of_abbreviations_for...

    Acronyms Diseases and disorders CA Cancer: CACH Childhood ataxia with central nervous system hypomyelination (see vanishing white matter disease) : CAD Coronary artery disease

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