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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.
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 ...
Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various ...
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 ...
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 ...
A standard operating procedure (SOP) is a set of step-by-step instructions compiled by an organization to help workers carry out routine operations. [1] SOPs aim to achieve efficiency, quality output, and uniformity of performance, while reducing miscommunication and failure to comply with industry regulations. [citation needed]
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.
In the U.S. the CDA standard is probably best known as the basis for the Continuity of Care Document (CCD) specification, based on the data model as specified by ASTM's Continuity of Care Record. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards. [citation needed]