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SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1][2] Documenting patient encounters in the medical record is an integral part of practice ...
Online doctor. Online doctor is a term that emerged during the 2000s, used by both the media [1] and academics, to describe a generation of physicians and health practitioners who deliver healthcare, including drug prescription, over the internet.
Clinical decision support system. A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow.
Electronic consultation. Electronic consultation is an aspect of telemedicine which involves remote communication between patients and clinicians, or between clinicians and specialists. E-consult was one of the earlier applications which primary care physicians could use to consult specialists. Dermatology [1] lent itself to this approach as ...
Radiography is an important tool in diagnosis of certain disorders. Medical diagnosis (abbreviated Dx, [1] Dx, or Ds) is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as a diagnosis with the medical context being implicit. The information required for a diagnosis is ...
Medical history. The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the ...
002274. [edit on Wikidata] In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on ...
Where available, ICD-10 codes are listed. When codes are available both as a sign/symptom (R code) and as an underlying condition, the code for the sign is used. When there is no symptoms for a disease that a patient has, the patient is said to be asymptomatic.
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