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  2. Operative report - Wikipedia

    en.wikipedia.org/wiki/Operative_report

    An Operative report is a report written in a patient's medical record to document the details of a surgery. [1] The operative report is dictated right after a surgical procedure and later transcribed into the patient's record.

  3. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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 ...

  4. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

  5. Operations manual - Wikipedia

    en.wikipedia.org/wiki/Operations_manual

    It documents the approved standard procedures for performing operations safely to produce goods and provide services. [2] Compliance with the operations manual will generally be considered as activity approved by the persons legally responsible for the organisation. [3] The operations manual is intended to remind employees of how to do their job.

  6. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...

  7. SBAR - Wikipedia

    en.wikipedia.org/wiki/SBAR

    SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication.This communication model has gained popularity in healthcare settings, especially amongst professions such as physicians and nurses.

  8. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes ...

  9. Hospital information system - Wikipedia

    en.wikipedia.org/wiki/Hospital_information_system

    A hospital information system (HIS) is an element of health informatics that focuses mainly on the administrational needs of hospitals.In many implementations, a HIS is a comprehensive, integrated information system designed to manage all the aspects of a hospital's operation, such as medical, administrative, financial, and legal issues and the corresponding processing of services.