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Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various ...
A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient.
In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases.
Narrative medicine is the discipline of applying the skills used in analyzing literature to interviewing patients. [1] The premise of narrative medicine is that how a patient speaks about his or her illness or complaint is analogous to how literature offers a plot (an interconnected series of events) with characters (the patient and others) and is filled with metaphors (picturesque, emotional ...
In acute care settings, such as emergency rooms, reports of chest pain are among the most common chief complaints. [8] The most common complaint in ERs has been reported to be abdominal pain . [ 9 ] Among nursing home residents seeking treatment at ERs, respiratory symptoms, altered mental status, gastrointestinal symptoms , and falls are the ...
Google Docs is an online word processor and part of the free, web-based Google Docs Editors suite offered by Google. Google Docs is accessible via a web browser as a web-based application and is also available as a mobile app on Android and iOS and as a desktop application on Google's ChromeOS .
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. 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 ...
The terms EHR, electronic patient record (EPR) and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist. [6] The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations.