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Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
OSCAR has many features which computerize and coordinate the important functions of a medical clinic. oscarEncounter is the patient's electronic medical record. It contains all of the patient's medical information, including CPP (Cumulative Patient Profile), patient history, progress notes, forms, documents, consultations and more.
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes , preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. Personal health records combine many of the above features with portability, thus allowing a patient ...
Mental health informatics is a branch of health or clinical informatics focused on the use of information technology (IT) and information to improve mental health. Like health informatics, mental health informatics is a multidisciplinary field that promotes care delivery, research and education [1] as well as the technology and methodologies required to implement it.
OpenNotes is a research initiative and international movement located at Beth Israel Deaconess Medical Center (affiliated with Harvard Medical School), that focuses on making health care more open and transparent by encouraging doctors, nurses, therapists, and other health care professionals to share clinical visit notes with patients, facilitating patients' legal right to access to their own ...
Nightscout is a collection of software tools, including mobile clients, to enable DIY cloud-based continuous glucose monitoring "…for informational and educational purposes." [ 31 ] Individual components are available under various open-source licenses, including the GNU GPL , [ 32 ] GNU AGPL , [ 33 ] MIT License , [ 34 ] and BSD licenses .
This framework became widely used in both medical and mental health settings, offering a structured yet flexible approach to documentation that supported clinical reasoning and treatment planning. [65] [66] Progress notes also gained prominence in mental health, tracking clients’ clinical status and treatment progress across sessions.
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