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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.
In public health, contact tracing is the process of identifying people who may have been exposed to an infected person ("contacts") and subsequent collection of further data to assess transmission. [ 1 ] [ 2 ] By tracing the contacts of infected individuals, testing them for infection, and isolating or treating the infected, this public health ...
Meaning Origin language and etymology Example(s) capill-of or pertaining to hair Latin capillus, hair capillus: capit-pertaining to the head as a whole Latin caput, capit-, the head capitation, decapitation carcin-cancer: Greek καρκίνος (karkínos), crab carcinoma: cardi-of or pertaining to the heart: Greek καρδία (kardía), heart ...
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Health data are classified as either structured or unstructured. Structured health data is standardized and easily transferable between health information systems. [4] For example, a patient's name, date of birth, or a blood-test result can be recorded in a structured data format.
Definition: Clear definitions should be provided so that current and future data users will know what the data mean. Each data element should have clear meaning and acceptable values. Granularity: The attributes and values of data should be defined at the correct level of detail.
The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.
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 ...