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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 ...
The terms EHR, electronic patient record (EPR) and EMR have often been used interchangeably, but differences between the models are now being defined. 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 ...
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 ...
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 ...
Medical transcription editing is the process of listening to a voice-recorded file and comparing that to the transcribed report of that audio file, correcting errors as needed. Although speech recognition technology has become better at understanding human language, editing is still needed to ensure better accuracy.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history.
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