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It is sometimes also referred to as reason for encounter ( RFE ), presenting problem, problem on admission or reason for presenting. [citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician -recommended return, or other reason for a medical encounter. [2]
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history.
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice ...
The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the medical diagnosis ...
The Automatic Complaint-Letter Generator is a website that automatically generates complaint letters. The website was created by Scott Pakin in 1994. It allows users to submit the name of the individual or company that the complaint is directed toward. The program then generates a complaint letter that is "general enough to be true or fit ...
Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...
Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes ( SOAP ...
A Warning Letter is one of the Agency's principal means of achieving prompt voluntary compliance with the Act. [1] While the FDA generally determines violations through its own inspections, they can also issue one based on evidence from state personnel. [2] The FDA considers a warning letter informal and advisory.
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