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  2. 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 ...

  3. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting. [citation needed][1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician -recommended return, or other reason for a medical encounter. [2]

  4. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.

  6. 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 ...

  7. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [6][7] In contrast, a ...

  8. 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 ...

  9. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    Medical history. The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the ...

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