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SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice ...
SOCRATES is a mnemonic acronym used by emergency medical services, physicians, nurses, and other health professionals to evaluate the nature of pain that a patient is experiencing. Uses [ edit ] SOCRATES is used to gain an insight into the patient 's condition, and to allow the health care provider to develop a plan for dealing with it.
Example of informed consent document from the PARAMOUNT trial. Informed consent is a principle in medical ethics, medical law and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care. Pertinent information may include risks and benefits of treatments, alternative ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
Social history (medicine) In medicine, a social history (abbreviated " SocHx ") [1] is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.
Dental braces (also known as braces, orthodontic cases, or cases) are devices used in orthodontics that align and straighten teeth and help position them with regard to a person's bite, while also aiming to improve dental health. They are often used to correct underbites, as well as malocclusions, overbites, open bites, gaps, deep bites, cross ...
Types A doctor using a stethoscope to listen to a 15-month-old's abdomen Routine. The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening ...