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The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. 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 ...
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. 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.
This is important, as if significant numbers of patients refuse to take part in clinical trials because of dislike of computers then there will be bias in the study population. One of the earliest ePRO studies used a LINC-2 minicomputer to collect patient data. The majority of patients preferred the computer to paper data collection. [7]
All pathology tests and profiles are coded from the Read Codes, a clinical terminology originally developed by a General Practitioner, James Read, to describe all aspects of healthcare for his own use but subsequently adopted and further developed by the NHS. A small subset of the complete set of READ codes (which itself numbered 89,616 ...
Whereas randomized clinical trials usually only inspect one variable or very few variables, rarely reflecting the full picture of a complicated medical situation, the case report can detail many different aspects of the patient's medical situation (e.g. patient history, physical examination, diagnosis, psychosocial aspects, follow up). [8]
Radiography is an important tool in diagnosis of certain disorders.. Medical diagnosis (abbreviated Dx, [1] D x, or D s) is the process of determining which disease or condition explains a person's symptoms and signs.
A medical test is a medical procedure performed to detect, diagnose, or monitor diseases, disease processes, susceptibility, or to determine a course of treatment. Medical tests such as, physical and visual exams, diagnostic imaging, genetic testing, chemical and cellular analysis, relating to clinical chemistry and molecular diagnostics, are typically performed in a medical setting.
A LIMS traditionally has been designed to process and report data related to batches of samples from biology labs, water treatment facilities, drug trials, and other entities that handle complex batches of data. A LIS has been designed primarily for processing and reporting data related to individual patients in a clinical setting.