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  2. File:PSRO hospital discharge data set (PHDDS) - trainee ...

    en.wikipedia.org/wiki/File:PSRO_hospital...

    Main page; Contents; Current events; Random article; About Wikipedia; Contact us; Pages for logged out editors learn more

  3. 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]

  4. File:Uniform hospital discharge data - minimum data set (IA ...

    en.wikipedia.org/wiki/File:Uniform_hospital...

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  5. Medical social work - Wikipedia

    en.wikipedia.org/wiki/Medical_social_work

    In short, a medical social worker provides services in three domains: intake and psychosocial assessment, case management and supportive therapy, and discharge planning and ongoing care that extends after hospitalization. They are also involved in patient and staff education, as well as with policy research for health programs. [4]

  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. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    The HL7 Consolidated Clinical Document Architecture (C-CDA) is an XML-based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States.

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  9. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    A progress note is considered as containing noise when there is difference between the surface form of the entered text and the intended content. For instance, when a clinician enters "bp" instead of "blood pressure", or an acronym such as "ARF" that could mean "Acute Renal Failure" or "Acute Rheumatic Fever".

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