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  2. 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 ...

  3. Prospective payment system - Wikipedia

    en.wikipedia.org/wiki/Prospective_payment_system

    The FQHC PPS rate for Medicare (previously called the All Inclusive Reimbursement Rate), in contrast, is fixed at the same level across different health centers. [ 3 ] [ 4 ] Aside from FQHCs, other entities that provide outpatient services to Medicaid patients, that are also paid by a PPS methodology include:

  4. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the reasoning/evidence behind it.

  5. Adoption of electronic medical records in U.S. hospitals

    en.wikipedia.org/wiki/Adoption_of_Electronic...

    The physicians surveyed were those in the internal medicine, family medicine, and the pediatric units of the hospital. Prior to the survey, physicians were given eight hours of training by consultants on how to navigate the EMR system. The survey subsequently taken showed a response rate of 35% or 59 of 154 providers.

  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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...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. Physical examination - Wikipedia

    en.wikipedia.org/wiki/Physical_examination

    The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.

  8. Bundled payment - Wikipedia

    en.wikipedia.org/wiki/Bundled_payment

    Providers may seek to maximize profit by avoiding patients for whom reimbursement may be inadequate (e.g., patients who do not take their drugs as prescribed), by overstating the severity of an illness, by giving the lowest level of service possible, by not diagnosing complications of a treatment before the end date of the bundled payment, or ...

  9. Enterprise master patient index - Wikipedia

    en.wikipedia.org/wiki/Enterprise_master_patient...

    In computing, an enterprise[-wide] master patient index is a form of customer data integration (CDI) specific to the healthcare industry.Healthcare organizations and groups use EMPI to identify, match, merge, de-duplicate, and cleanse patient records to create a master index that may be used to obtain a complete and single view of a patient.