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Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
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 term is most commonly used in information given to the news media, and is rarely used as a clinical description by physicians. Two aspects of the patient's state may be reported. The first aspect is the patient's current state, which may be reported as "good" or "serious," for instance. Second, the patient's short-term prognosis may be ...
Prognosis (Greek: πρόγνωσις "fore-knowing, foreseeing"; pl.: prognoses) is a medical term for predicting the likelihood or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) or remain stable over time; expectations of quality of life, such as the ability to carry out daily activities; the potential for complications and ...
The method by which doctors gather information about a patient's past and present medical condition in order to make informed clinical decisions is called the history and physical (a.k.a. the H&P). The history requires that a clinician be skilled in asking appropriate and relevant questions that can provide them with some insight as to what the ...
Digital letters and text messages sent out to patients have saved a hospital money and cut down on missed appointments, it said. The Queen Elizabeth Hospital in King's Lynn, Norfolk, said the ...
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.
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