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CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: [1] Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology
When a section is a summary of another article that provides a full exposition of the section, a link to the other article should appear immediately under the section heading. You can use the {{ Main }} template to generate a "Main article" link, in Wikipedia's "hatnote" style.
If the abstract of a journal article is available on PubMed, use the {} template to add a link. If the article has a digital object identifier (DOI), use the {} template. If and only if the article's full text is freely available online, supply a uniform resource locator (URL) to this text by hyperlinking the article title in the citation. If ...
Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies. Family history The family history lists the health status of immediate family members as well as their causes of death (if known). [19] It may also list diseases common in the family or found only in one sex or the other.
The patient summary contains 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. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...
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A short description, with the {{Short description}} template; A disambiguation hatnote, most of the time with the {} template (see also Wikipedia:Hatnote § Hatnote templates) No-output templates that indicate the article's established date format and English-language variety, if any (e.g., {{Use dmy dates}}, {{Use Canadian English}})