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  2. Consolidated Clinical Document Architecture - Wikipedia

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

    Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...

  3. Continuity of Care Document - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Document

    The patient summary contains 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. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...

  4. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes , preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record.

  5. Early postnatal hospital discharge - Wikipedia

    en.wikipedia.org/wiki/Early_postnatal_hospital...

    Early postnatal hospital discharge generally refers to the postpartum hospital discharge of the mother and newborn within 48 hours. [1] The duration of what is considered "early discharge" varies between countries from 12 to 72 hours due to the differences in average duration of hospital stay. [ 2 ]

  6. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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 ...

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    AOL Mail welcomes Verizon customers to our safe and delightful email experience!

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  9. Electronic prescribing - Wikipedia

    en.wikipedia.org/wiki/Electronic_prescribing

    The prescriber, generally a clinician or healthcare staff, is defined as the electronic prescribing system user and sign into the system through a verification process to authenticate their identity.

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