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2. 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 ...

3. Case report form - Wikipedia

   en.wikipedia.org/wiki/Case_report_form

   A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [ 1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient. All data on each patient participating in a clinical trial are held and/or documented in the CRF ...

4. Operative report - Wikipedia

   en.wikipedia.org/wiki/Operative_report

   Operative report. An Operative report is a report written in a patient's medical record to document the details of a surgery. [ 1] The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after ...

5. 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 ...

6. 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 ...

7. List of open-source health software - Wikipedia

   en.wikipedia.org/wiki/List_of_open-source_health...

   Endrov Image and data viewer and editor. It is available under the BSD license. [40] GIMIAS is a workflow-oriented environment focused on biomedical image computing and simulation. It is available under a BSD-style license. [41] Ginkgo CADx Cross-platform open source DICOM viewer and dicomizer.