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  2. Incident report - Wikipedia

    en.wikipedia.org/wiki/Incident_report

    In a health care facility, such as a hospital, nursing home, or assisted living, an incident report or accident report is a form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient.

  3. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.

  4. Operative report - Wikipedia

    en.wikipedia.org/wiki/Operative_report

    The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. 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 ...

  5. Occupational Safety and Health Administration - Wikipedia

    en.wikipedia.org/wiki/Occupational_Safety_and...

    Receive copies of records of work-related injuries and illnesses that occur in their workplace. Receive copies of the results from tests and monitoring conducted to identify and measure hazards in their workplace. Receive copies of their workplace medical records. Participate in an OSHA inspection and speak in private with the inspector.

  6. Personal health record - Wikipedia

    en.wikipedia.org/wiki/Personal_health_record

    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.

  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 ...

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