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2. Operative report - Wikipedia

   en.wikipedia.org/wiki/Operative_report

   The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx), physical examination (PE), consent forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]

3. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   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 ...

4. Medical record - Wikipedia

   en.wikipedia.org/wiki/Medical_record

   The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for ...

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. 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.

7. ‘Doctors Dismissed My Chronic Cough As Allergies. It Was ...

   www.aol.com/lifestyle/doctors-dismissed-chronic...

   Jessica DeCristofaro was diagnosed with stage 4B Hodgkin’s lymphoma, a rare form of cancer, at 28 years old. Here, she shares her story and what doctors missed. ‘Doctors Dismissed My Chronic ...