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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 ...
Health care provider. A health care provider is an individual health professional or a health facility organization licensed to provide health care diagnosis and treatment services including medication, surgery and medical devices. Health care providers often receive payments for their services rendered from health insurance providers.
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]
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 ...
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 ...
Health professional. A health professional, healthcare professional, or healthcare worker (sometimes abbreviated HCW) [1] is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician (such as family physician, internist, obstetrician, psychiatrist, radiologist ...
Medical laboratory. Clinical laboratory in a hospital setting showing several automated analysers. A medical laboratory or clinical laboratory is a laboratory where tests are conducted out on clinical specimens to obtain information about the health of a patient to aid in diagnosis, treatment, and prevention of disease. [1]
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 ...