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Hospitals in NHS Surrey Archived 2012-04-04 at the Wayback Machine are also sending documents electronically to GP practices and also Coventry and Warwickshire and Herefordshire PCT are delivering to GP practices via EDT Hub. Documents typically handled by EDT Hub include: Discharge Summaries; Discharge Letters; Encounter Reports; Radiology Reports
CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: [1] Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology
A Summary Care Record (SCR) is an electronic patient record, a summary of National Health Service patient data held on a central database covering England, part of the NHS National Programme for IT. The purpose of the database is to make patient data readily available anywhere that the patient seeks treatment, for example if they are staying ...
Sample view of an electronic health record. An electronic health record (EHR) also known as an electronic medical record (EMR) or personal health record (PHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings.
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.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
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