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Electronic Forms and Signature Capture – patient intake forms, new patient forms, consent forms, health history forms, HIPAA portability forms, and other data-driven or signature captured forms are prevalent in today's healthcare organizations. Unfortunately, the majority of them are paper-based as of the time this article was written.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are ...
The Patient-Reported Outcomes Measurement Information System [1] (PROMIS) provides clinicians and researchers access to reliable, valid, and flexible measures of health status that assess physical, mental, and social well–being from the patient perspective. PROMIS measures are standardized, allowing for assessment of many patient-reported ...
In some cases, an instrument may be developed and validated from the beginning in electronic form. More commonly, perhaps, new instruments will be developed in parallel for paper and electronic use, as is the case with the PROMIS (Patient-Reported Outcomes Measurement Information System) initiative. [15]
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 ...
Health professionals use online patient education to prepare patients for medical procedures, administer intake and informed consent paperwork, educate patients about health conditions, provide information about preventive care, encourage healthy behavior and lifestyle changes, etc. Health insurance companies use online patient education to inform patients about coverage policies.
The purpose of the intake interview often includes establishing and diagnosing any problems the client may have. [1] Usually, the clinician diagnoses the patient using criteria from the first two DSM axes. Some intake interviews include a mental status examination [2] During the intake interview, the clinician may determine a treatment plan. In ...