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2. Doctor's visit - Wikipedia

   en.wikipedia.org/wiki/Doctor's_visit

   Doctor's visit. A doctor meeting with her patient in Egypt. Doctors develop a close relationship with their patients in order to build trust and better diagnose and treat disease. A doctor's visit, also known as a physician office visit or a consultation, or a ward round in an inpatient care context, is a meeting between a patient with a ...

3. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice ...

4. Consolidated Clinical Document Architecture - Wikipedia

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

   The HL7 Consolidated Clinical Document Architecture ( C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1] [2] [3] All certified Electronic health records in the United States are required to ...

5. Informed consent - Wikipedia

   en.wikipedia.org/wiki/Informed_consent

   Example of informed consent document from the PARAMOUNT trial. Informed consent is a principle in medical ethics, medical law and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care. Pertinent information may include risks and benefits of treatments, alternative ...

6. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.

7. Calgary–Cambridge model - Wikipedia

   en.wikipedia.org/wiki/Calgary–Cambridge_model

   Calgary–Cambridge model. The Calgary–Cambridge model ( Calgary-Cambridge guide) is a method for structuring medical interviews. It focuses on giving a clear structure of initiating a session, gathering information, physical examination, explaining results and planning, and closing a session. It is popular in medical education in many countries.

8. Medical record - Wikipedia

   en.wikipedia.org/wiki/Medical_record

   A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...

9. 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 ( SOAP ...