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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. 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 ...

4. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.

5. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...

6. Medical Nutrition Therapy: How It Works, Conditions, and More

   www.healthline.com/nutrition/nutrition-therapy

   Medical nutrition therapy is a specialized, dietician-developed regimen used to treat certain diseases, such as diabetes. This article tells you everything you need to know about medical nutrition ...

7. Electronic health record - Wikipedia

   en.wikipedia.org/wiki/Electronic_health_record

   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 ...

8. 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.

9. AVPU - Wikipedia

   en.wikipedia.org/wiki/AVPU

   AVPU. The AVPU scale (an acronym from "alert, verbal, pain, unresponsive") is a system by which a health care professional can measure and record a patient's level of consciousness. [1] It is mostly used in emergency medicine protocols, and within first aid. It is a simplification of the Glasgow Coma Scale, which assesses a patient response in ...