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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. Operative report - Wikipedia

   en.wikipedia.org/wiki/Operative_report

   The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx), physical examination (PE), consent forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]

4. Evidence-based dentistry - Wikipedia

   en.wikipedia.org/wiki/Evidence-based_Dentistry

   Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences. —

5. Dentistry - Wikipedia

   en.wikipedia.org/wiki/Dentistry

   It is an approach to oral health that requires the application and examination of relevant scientific data related to the patient's oral and medical health. Along with the dentist's professional skill and expertise, EBD allows dentists to stay up to date on the latest procedures and patients to receive improved treatment.

6. Medical history - Wikipedia

   en.wikipedia.org/wiki/Medical_history

   Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient. History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information.

7. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   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 ...