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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

    Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various ...

  4. Case report form - Wikipedia

    en.wikipedia.org/wiki/Case_report_form

    A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient.

  5. 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.

  6. Case report - Wikipedia

    en.wikipedia.org/wiki/Case_report

    Whereas randomized clinical trials usually only inspect one variable or very few variables, rarely reflecting the full picture of a complicated medical situation, the case report can detail many different aspects of the patient's medical situation (e.g. patient history, physical examination, diagnosis, psychosocial aspects, follow up). [8]

  7. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    In acute care settings, such as emergency rooms, reports of chest pain are among the most common chief complaints. [8] The most common complaint in ERs has been reported to be abdominal pain . [ 9 ] Among nursing home residents seeking treatment at ERs, respiratory symptoms, altered mental status, gastrointestinal symptoms , and falls are the ...

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    www.aol.com/products/utilities/ad-free-mail

    Ad-Free AOL Mail offers you the AOL webmail experience minus paid ads, allowing you to focus on your inbox without distractions, for just $4.99 per month. Get Ad-Free AOL Mail Get a more ...

  9. Patient-reported outcome - Wikipedia

    en.wikipedia.org/wiki/Patient-reported_outcome

    The patient-reported perspective can be an important asset in gaining treatment or drug approval. [1] [2] There is no incentive for patients to report their outcome data other than to "pay it forward" to the community and help the health industry prevent unnecessary suffering in other patients. [citation needed]

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