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2. 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.

3. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   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 ...

4. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various ...

5. Medical transcription - Wikipedia

   en.wikipedia.org/wiki/Medical_transcription

   This record is often called the patient's "chart" in a hospital setting. Medical transcription encompasses the medical transcriptionist, performing document typing and formatting functions according to an established criterion or format, transcribing the spoken word of the patient's care information into a written, easily readable form.

6. Medication Administration Record - Wikipedia

   en.wikipedia.org/wiki/Medication_Administration...

   A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...

7. Health information management - Wikipedia

   en.wikipedia.org/wiki/Health_information_management

   The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.

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9. Electronic health record - Wikipedia

   en.wikipedia.org/wiki/Electronic_health_record

   Providing patients with information is central to patient-centered health care and this has been shown to have some positive effects on health outcomes. [22] Providing patients with access to their health records including medical histories and test results via an electronic health record is a legal right in some parts of the world. [22]