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  2. Medical transcription - Wikipedia

    en.wikipedia.org/wiki/Medical_transcription

    Medical transcription, also known as MT, is an allied health profession dealing with the process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners. Medical reports can be voice files, notes taken during a lecture, or other spoken material.

  3. SAMPLE history - Wikipedia

    en.wikipedia.org/wiki/SAMPLE_History

    It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]

  4. Operative report - Wikipedia

    en.wikipedia.org/wiki/Operative_report

    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 forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]

  5. List of medical abbreviations - Wikipedia

    en.wikipedia.org/wiki/List_of_medical_abbreviations

    Pronunciation follows convention outside the medical field, in which acronyms are generally pronounced as if they were a word (JAMA, SIDS), initialisms are generally pronounced as individual letters (DNA, SSRI), and abbreviations generally use the expansion (soln. = "solution", sup. = "superior").

  6. Case report form - Wikipedia

    en.wikipedia.org/wiki/Case_report_form

    Case report forms contain data obtained during the patient's participation in the clinical trial. Before being sent to the sponsor, this data is usually de-identified (not traceable to the patient) by removing the patient's name, medical record number, etc., and giving the patient a unique study number.

  7. 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.

  8. CareCloud - Wikipedia

    en.wikipedia.org/wiki/CareCloud

    CareCloud was founded as Medical Transcription Billing Corporation (MTBC) in 1999 by American entrepreneur Mahmud Haq. [4] The earliest days of the company were focused on providing transcription and manual medical billing to healthcare providers primarily located in New Jersey. [5] [6] [7] [8]

  9. Clinical study report - Wikipedia

    en.wikipedia.org/wiki/Clinical_study_report

    In medicine, a clinical study report (CSR) on a clinical trial is a document, typically very long, providing much detail about the methods and results of a trial. A CSR is a scientific document addressing efficacy and safety, not a sales or marketing tool; its content is similar to that of a peer-reviewed academic paper. [ 1 ]

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