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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. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and ...

  4. Patient diary - Wikipedia

    en.wikipedia.org/wiki/Patient_diary

    A patient diary is a tool used during a clinical trial or a disease treatment to assess the patient's condition (e.g. symptom severity, quality of life) or to measure treatment compliance. An electronic patient diary registers the data in a storage device and allows for automatically monitoring the time the entry was made.

  5. Case report form - Wikipedia

    en.wikipedia.org/wiki/Case_report_form

    The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient. All data on each patient participating in a clinical trial are held and/or documented in the CRF, including adverse events.

  6. Remote patient monitoring - Wikipedia

    en.wikipedia.org/wiki/Remote_patient_monitoring

    This form of patient monitoring can be particularly important when patients are managing complex self-care processes such as home hemodialysis. [ 3 ] Key features of RPM, like remote monitoring and trend analysis of physiological parameters, enable early detection of deterioration; thereby reducing emergency department visits, hospitalizations ...

  7. Patient management software - Wikipedia

    en.wikipedia.org/wiki/Patient_management_software

    Patient management software is classified as either Class I or Class II. Software that is intended to be used to view images, or other real time data, as an adjunct to the monitoring device itself, for the purpose of aiding in treatment or diagnosis of a patient, would be Class I medical devices.

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  9. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are ...

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