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2. 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.

3. Electronic health record - Wikipedia

   en.wikipedia.org/wiki/Electronic_health_record

   Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [12] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.

4. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...

5. Admission note - Wikipedia

   en.wikipedia.org/wiki/Admission_note

   An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]

6. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   They are the repository of medical facts and clinical thinking, and are intended to be a concise vehicle of communication about a patient’s condition to those who access the health record. The majority of the medical record consists of progress notes documenting the care delivered and the clinical events relevant to diagnosis and treatment ...

7. 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.

8. 50 Interesting Medical Cases That Might Make You ... - AOL

   www.aol.com/59-medical-cases-fascinating-bizarre...

   Digital health records have replaced the old system of paper files, making healthcare more efficient and less prone to errors. Doctors can now access your medical history in seconds, enabling ...

9. Protected health information - Wikipedia

   en.wikipedia.org/wiki/Protected_health_information

   For example, sharing information about someone on the street with an obvious medical condition such as an amputation is not restricted by U.S. law. However, obtaining information about the amputation exclusively from a protected source, such as from an electronic medical record, would breach HIPAA regulations. Business Associates