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  2. Consolidated Clinical Document Architecture - Wikipedia

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

    It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. [ 12 ] Procedure Note - Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.The Procedure Note is created immediately ...

  3. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.

  4. Fast Healthcare Interoperability Resources - Wikipedia

    en.wikipedia.org/wiki/Fast_Healthcare...

    The Sync for Science (S4S) profile builds on FHIR to help medical research studies ask for (and if approved by the patient, receive) patient-level electronic health record data. [18] In January, 2018, Apple announced that its iPhone Health App would allow viewing a user's FHIR-compliant medical records when providers choose to make them ...

  5. Medication Administration Record - Wikipedia

    en.wikipedia.org/wiki/Medication_Administration...

    A Medication Administration Record [1] (MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical chart. The health care ...

  6. Electronic health records in the United States - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_records...

    Electronic medical records, like other medical records, must be kept in unaltered form and authenticated by the creator. [24] Under data protection legislation, the responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility.

  7. Continuity of Care Document - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Document

    The public library is relatively limited of reference CCDs available for developers to examine how to encode medical data using the structure and format of the CCD. Not surprisingly, different electronic health record vendors have implemented the CCD standard in different and often incompatible ways. [5]

  8. Case report form - Wikipedia

    en.wikipedia.org/wiki/Case_report_form

    Case report forms contain data obtained during the patient's participation in the clinical trial. Before being sent to the sponsor, this data is usually de-identified (not traceable to the patient) by removing the patient's name, medical record number, etc., and giving the patient a unique study number.

  9. 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").