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  2. Patient check-in - Wikipedia

    en.wikipedia.org/wiki/Patient_Check-In

    Electronic Forms and Signature Capture – patient intake forms, new patient forms, consent forms, health history forms, HIPAA portability forms, and other data-driven or signature captured forms are prevalent in today's healthcare organizations. Unfortunately, the majority of them are paper-based as of the time this article was written.

  3. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]

  4. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The physician will take a history of present illness, or HPI, of the CC. [1] This describes the patient's current condition in narrative form, from the time of initial sign/symptom to the present. [10] It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded. [1]

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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.

  6. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient. History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information.

  7. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...

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