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  2. Operative report - Wikipedia

    en.wikipedia.org/wiki/Operative_report

    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 ...

  3. Focused assessment with sonography for trauma - Wikipedia

    en.wikipedia.org/wiki/Focused_assessment_with_s...

    Focused assessment with sonography in trauma (commonly abbreviated as FAST) is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart (pericardial effusion) or abdominal organs (hemoperitoneum) after trauma.

  4. Physical examination - Wikipedia

    en.wikipedia.org/wiki/Physical_examination

    The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.

  5. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Example Comments chief complaint (CC) "abdominal pain" Can also include a more detailed line, such as "30 yo F c/o abdominal pain", though this can be redundant to the HPI. Some notes include a "reason for consultation", which is similar but may address a physical finding from a physician as opposed to a symptom from a patient.

  6. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.

  7. List of surgical procedures - Wikipedia

    en.wikipedia.org/wiki/List_of_surgical_procedures

    The field of minimally invasive surgery has spawned another set of words, such as arthroscopic or laparoscopic surgery. These take the same form as above; an ...

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  9. Intraoperative neurophysiological monitoring - Wikipedia

    en.wikipedia.org/wiki/Intraoperative...

    Intraoperative neurophysiological monitoring (IONM) or intraoperative neuromonitoring is the use of electrophysiological methods such as electroencephalography (EEG), electromyography (EMG), and evoked potentials to monitor the functional integrity of certain neural structures (e.g., nerves, spinal cord and parts of the brain) during surgery.