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Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
For example, according to works later ascribed to him, [6] he was the first to describe epilepsy as an inheritable brain disease rather than an infliction from the divine. [8] In addition to his rejection of purely divine causes of illness, Hippocrates rejected the idea that medicine could only be practiced by those born into the priestly ...
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 ...
Prognosis (Greek: πρόγνωσις "fore-knowing, foreseeing"; pl.: prognoses) is a medical term for predicting the likelihood or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) or remain stable over time; expectations of quality of life, such as the ability to carry out daily activities; the potential for complications and ...
The term is most commonly used in information given to the news media, and is rarely used as a clinical description by physicians. Two aspects of the patient's state may be reported. The first aspect is the patient's current state, which may be reported as "good" or "serious," for instance. Second, the patient's short-term prognosis may be ...
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. [1]
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.
In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness. The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and ...