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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 ...
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 ...
Your medical history includes both your personal health history and your family health history. Your personal health history has details about any health problems you’ve ever had. A family ...
Positive: The lab found whatever your doctor was testing for. So if you had a test for strep throat, testing positive means you do have strep throat. Negative: The lab didn’t find whatever you ...
Blood pressure is a measurement of the extent of the force of blood on your blood vessel walls as your heart pumps. It’s measured in millimeters of mercury (mm Hg). Systolic blood pressure is ...
A pathology report is a medical document that gives information about a diagnosis, such as cancer. To test for the disease, a sample of your suspicious tissue is sent to a lab. A doctor called a ...
A pain scale is a tool that doctors use to help assess a person’s pain. A person usually self-reports their pain using a specially designed scale, sometimes with the help of a doctor, parent, or ...