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  2. Medical transcription - Wikipedia

    en.wikipedia.org/wiki/Medical_transcription

    Medical transcription, also known as MT, is an allied health profession dealing with the process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners. Medical reports can be voice files, notes taken during a lecture, or other spoken material.

  3. Operative report - Wikipedia

    en.wikipedia.org/wiki/Operative_report

    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 forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]

  4. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...

  5. List of abbreviations used in medical prescriptions - Wikipedia

    en.wikipedia.org/wiki/List_of_abbreviations_used...

    This is a list of abbreviations used in medical prescriptions, including hospital orders (the patient-directed part of which is referred to as sig codes).This list does not include abbreviations for pharmaceuticals or drug name suffixes such as CD, CR, ER, XT (See Time release technology § List of abbreviations for those).

  6. List of eponymous medical signs - Wikipedia

    en.wikipedia.org/wiki/List_of_eponymous_medical...

    Eponymous medical signs are those that are named after a person or persons, usually the physicians who first described them, but occasionally named after a famous patient. This list includes other eponymous entities of diagnostic significance; i.e. tests, reflexes, etc.

  7. List of medical abbreviations - Wikipedia

    en.wikipedia.org/wiki/List_of_medical_abbreviations

    Pronunciation follows convention outside the medical field, in which acronyms are generally pronounced as if they were a word (JAMA, SIDS), initialisms are generally pronounced as individual letters (DNA, SSRI), and abbreviations generally use the expansion (soln. = "solution", sup. = "superior").

  8. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    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.

  9. Automated medical scribe - Wikipedia

    en.wikipedia.org/wiki/Automated_medical_scribe

    The privacy protections of automated medical scribes vary widely. While it is possible to do all the transcription and summarizing locally, with no connection to the internet, most closed-source providers require that data be sent to their own servers over the internet, processed there, and the results sent back (as with digital voice assistants).