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2. Medical record - Wikipedia

   en.wikipedia.org/wiki/Medical_record

   The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease state.

3. Personal health record - Wikipedia

   en.wikipedia.org/wiki/Personal_health_record

   The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.

4. SOAP note - Wikipedia

   en.wikipedia.org/wiki/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 recordis an integral part of practice workflow starting ...

5. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...

6. Electronic health record - Wikipedia

   en.wikipedia.org/wiki/Electronic_health_record

   Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [13] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.

7. Review of systems - Wikipedia

   en.wikipedia.org/wiki/Review_of_systems

   A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).