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Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR. [2] Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5]
The Prescribing Information follows one of two formats: "physician labeling rule" format or "old" (non-PLR) format. For "old" format labeling a "product title" may be listed first and may include the proprietary name (if any), the nonproprietary name, dosage form(s), and other information about the product. The other sections are as follows:
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]
A 2015 study of five European medical schools found that students who used Wikipedia for general information were more likely to use it to look up medical information. 16% of students used Wikipedia often for general information, 60% sometimes, and 24% rarely. 12% of students used Wikipedia often for medical information, 55% sometimes, and 33% ...
The Patient-Reported Outcomes Measurement Information System [1] (PROMIS) provides clinicians and researchers access to reliable, valid, and flexible measures of health status that assess physical, mental, and social well–being from the patient perspective. PROMIS measures are standardized, allowing for assessment of many patient-reported ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
A 2016 study found that many patients consider side effects to be important information to be included on a prescription package and that auxiliary labels are a good tool to provide this information on the packaging itself (as opposed to a separate information sheet/handout). [9]
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.