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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. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. 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 ...

  4. OPQRST - Wikipedia

    en.wikipedia.org/wiki/OPQRST

    Each letter stands for an important line of questioning for the patient assessment. [ 3 ] [ 4 ] This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of a SOAP note , for later reference.

  5. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    Medical history. The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the ...

  6. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...

  7. Roaches in the operating room: Doctors at HCA hospital in ...

    www.aol.com/news/roaches-operating-room-doctors...

    On Dec. 7, 2021, more than a dozen surgeons convened a meeting at their hospital, HCA Florida Bayonet Point in Hudson, Florida. Their concerns about patient safety at the 290-bed acute care ...

  8. Medical Priority Dispatch System - Wikipedia

    en.wikipedia.org/wiki/Medical_Priority_Dispatch...

    Each dispatch determinant is made up of three pieces of information, which builds the determinant in a number-letter-number format. The first component, a number from 1 to 36, indicates a complaint or specific protocol from the MPDS: the selection of this card is based on the initial questions asked by the emergency dispatcher.

  9. 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 ...

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