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  2. Consolidated Clinical Document Architecture - Wikipedia

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

    Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...

  3. Electronic referrals - Wikipedia

    en.wikipedia.org/wiki/Electronic_Referrals

    Clinical Document Architecture (CDA) is an international standard developed by the organisation Health Level 7 International, [10] outlining the unvarying structure and presentation for clinical documents like that of e-referrals. The CDA: Provides a consistent structure for e-referral clinical information

  4. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...

  5. Continuity of Care Document - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Document

    In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]

  6. Referral (medicine) - Wikipedia

    en.wikipedia.org/wiki/Referral_(medicine)

    Patients can be referred to another medical clinic by request. In medicine, referral is the transfer of care for a patient from one clinician or clinic to another by request. [1] [2] Tertiary care is usually done by referral from primary or secondary medical care personnel.

  7. Medical certificate - Wikipedia

    en.wikipedia.org/wiki/Medical_certificate

    Medical certificates are often used to certify that someone is free of contagious diseases, drug addiction, mental illness, or other health issues. Health criteria are often required when making an application for something, such as an eye examination to get a driver's license.

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  9. 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]

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