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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 ...
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 ...
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
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]
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 ...
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.
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.
Computerized physician order entry. Computerized physician order entry ( CPOE ), sometimes referred to as computerized provider order entry or computerized provider order management ( CPOM ), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her ...