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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.
The history of medicine is both a study of medicine throughout history as well as a multidisciplinary field of study that seeks to explore and understand medical practices, both past and present, throughout human societies. [1] The history of medicine is the study and documentation of the evolution of medical treatments, practices, and ...
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]
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
History of medical diagnosis. The history of medical diagnosis began in earnest from the days of Imhotep in ancient Egypt and Hippocrates in ancient Greece but is far from perfect despite the enormous bounty of information made available by medical research including the sequencing of the human genome. The practice of diagnosis continues to be ...
For prescriptions, see Electronic prescribing. An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. [ 1 ] These records can be shared across different health care settings.
Medical guideline. A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare. Such documents have been in use for thousands of years during the ...
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.
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