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The clinical data repository is not without its weaknesses, however. Since they usually don't integrate with other non-clinical sources, following patient treatment across the care continuum becomes very difficult. In turn, tracking the true cost per case for each patient isn't feasible.
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]
The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken.
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.
Regardless of being in a paper form or electronic form, a medical health record is a tool of communication which helps in making clinical decisions, designing regulatory processes, accreditation, education, legal protection, research purposes, service coordination and evaluation of the efficacy and quality of healthcare provided. [1]
Some patient portal applications enable patients to register and complete forms online, which can streamline visits to clinics and hospitals. Many portal applications also enable patients to request prescription refills online, order eyeglasses and contact lenses, access medical records, pay bills, review lab results, and schedule medical ...
Valderas JM, Alonso J. Patient reported outcome measures: a model-based classification system for research and clinical practice. Qual Life Res. 2008; 17: 1125–35. Wiklund I., Assessment of patient-reported outcomes in clinical trials: the example of health-related quality of life, Fundam Clin Pharmacol. 2004 Jun;18(3):351-63.
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.