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Original file (725 × 612 pixels, file size: 52 KB, MIME type: application/pdf, 2 pages) This is a file from the Wikimedia Commons . Information from its description page there is shown below.
Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
They should be readable, easily understood, complete, accurate, and concise. They must also be flexible enough to logically convey to others what happened during an encounter, e.g., the chain of events during the visit, as well as guaranteeing full accountability for documented material, e.g., who recorded the information and when it was recorded.
The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...
An after action report (or AAR) is any form of retrospective analysis on a given sequence of goal-oriented actions previously undertaken, generally by the author themselves. The two principal forms of AARs are the literary AAR, intended for recreational use, and the analytical AAR, exercised as part of a process of performance evaluation and ...
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The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies. Family history The family history lists the health status of immediate family members as well as their causes of death (if known). [19] It may also list diseases common in the family or found only in one sex or the other.
Example of a front page of a report. A report is a document or a statement that presents information in an organized format for a specific audience and purpose. Although summaries of reports may be delivered orally, complete reports are usually given in the form of written documents.