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  2. Hospital emergency codes - Wikipedia

    en.wikipedia.org/wiki/Hospital_emergency_codes

    Hospital emergency codes are coded messages often announced over a public address system of a hospital to alert staff to various classes of on-site emergencies. The use of codes is intended to convey essential information quickly and with minimal misunderstanding to staff while preventing stress and panic among visitors to the hospital.

  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. 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 ...

  5. 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 ...

  6. Medical error - Wikipedia

    en.wikipedia.org/wiki/Medical_error

    For example, visual illusions can cause radiologists to misperceive images. [71] A number of Information Technology (IT) systems have been developed to detect and prevent medication errors, the most common type of medical errors. [72] These systems screen data such as ICD-9 codes, pharmacy and laboratory data.

  7. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    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 ...

  8. List of abbreviations used in medical prescriptions - Wikipedia

    en.wikipedia.org/wiki/List_of_abbreviations_used...

    This is a list of abbreviations used in medical prescriptions, including hospital orders (the patient-directed part of which is referred to as sig codes). This list does not include abbreviations for pharmaceuticals or drug name suffixes such as CD, CR, ER, XT (See Time release technology ยง List of abbreviations for those).

  9. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    It is sometimes also referred to as reason for encounter ( RFE ), presenting problem, problem on admission or reason for presenting. [citation needed][ 1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician -recommended return, or other reason for a medical encounter. [ 2]