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  2. Case report form - Wikipedia

    en.wikipedia.org/wiki/Case_report_form

    Case report forms contain data obtained during the patient's participation in the clinical trial. Before being sent to the sponsor, this data is usually de-identified (not traceable to the patient) by removing the patient's name, medical record number, etc., and giving the patient a unique study number.

  3. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds. [2] Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR. [2] Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5 ...

  4. 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.

  5. Medical certificate - Wikipedia

    en.wikipedia.org/wiki/Medical_certificate

    A medical certificate or doctor's certificate [1] [2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [3] It can serve as a sick note ( UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition.

  6. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    An electronic health record ( EHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including ...

  7. Medication Administration Record - Wikipedia

    en.wikipedia.org/wiki/Medication_Administration...

    Medication Administration Record. A Medication Administration Record [1] ( MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical ...

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