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"Doctor" codes are often used in hospital settings for announcements over a general loudspeaker or paging system that might cause panic or endanger a patient's privacy. Most often, "doctor" codes take the form of "Paging Dr. Sinclair", where the doctor's "name" is a code word for a dangerous situation or a patient in crisis, e.g.: "Paging Dr ...
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 ...
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 ...
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 ...
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 ...
A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient. All data on each patient participating in a clinical trial are held and/or documented in the CRF ...
The Morbidity and Mortality Weekly Report ( MMWR) is a weekly epidemiological digest for the United States published by the Centers for Disease Control and Prevention (CDC). It was originally established as Weekly Health Index in 1930, changing its title to Weekly Mortality Index in 1941 and Morbidity and Mortality in 1952.
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