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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 forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]
The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their ...
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).
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".
In July 1920, the first issue of Archives of Surgery was published by the American Medical Association.William J. Mayo, MD, who was a member of the editorial board and authored the inaugural editorial, indicated that Archives of Surgery would follow the character and scope of its sister journals, Archives of Internal Medicine, Archives of Neurology and Psychiatry, and the American Journal of ...
It is the official journal of several European surgical societies: German Society of Surgery, German Society of General and Visceral Surgery, German Association of Endocrine Surgeons, European Society of Endocrine Surgeons, and the German, Austrian and Swiss Surgical Associations for Minimal Invasive Surgery. The journal is currently published ...
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.
Surgery is a monthly peer-reviewed medical journal covering surgery. It was established in 1937 and is published by Elsevier . It is sponsored by the Society of University Surgeons , the Central Surgical Association , and the American Association of Endocrine Surgeons .