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  2. 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).

  3. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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 ...

  4. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    Whatever system a specific condition may seem restricted to, all the other systems are usually reviewed in a comprehensive history. The review of systems often includes all the main systems in the body that may provide an opportunity to mention symptoms or concerns that the individual may have failed to mention in the history.

  5. Preferred Reporting Items for Systematic Reviews and Meta ...

    en.wikipedia.org/wiki/Preferred_reporting_items...

    The PRISMA flow diagram, depicting the flow of information through the different phases of a systematic review. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) is an evidence-based minimum set of items aimed at helping scientific authors to report a wide array of systematic reviews and meta-analyses, primarily used to assess the benefits and harms of a health care ...

  6. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    review of systems (ROS) "negative except as above" Brief or handwritten ROS sections are often very brief, while template-driven ROS sections from electronic medical records often explicitly enumerate each system reviewed. allergies "NKDA" including drug allergies (including antigens and responses). "NKA" = "no known allergies".

  7. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.

  8. Cochrane Library - Wikipedia

    en.wikipedia.org/wiki/Cochrane_Library

    This creates a review of studies, or systematic review, giving a comprehensive view of the efficacy of a particular medical intervention. Finished reviews are available as a full report with diagrams, in condensed form or as a plain language summary, in order to provide for every reader of the review. [9]

  9. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    [citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]