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  2. Hospital emergency codes - Wikipedia

    en.wikipedia.org/wiki/Hospital_emergency_codes

    Code Grey - Physical threat requiring Security. Code Blue - Cardiac/Respiratory arrest OR non-patient (visitor, staff) medical emergency or patient in non-clinical area ALSO “MET call” medical emergency or deteriorating patient in a clinical area. Code Yellow - Internal emergency. Code Brown - External disaster.

  3. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.

  4. 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 ...

  5. Adoption of electronic medical records in U.S. hospitals

    en.wikipedia.org/wiki/Adoption_of_Electronic...

    The adoption of electronic medical records refers to the recent shift from paper-based medical records to electronic health records (EHRs) in hospitals. The move to electronic medical records is becoming increasingly prevalent in health care delivery systems in the United States, with more than 80% of hospitals adopting some form of EHR system ...

  6. 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 ...

  7. Personal health record - Wikipedia

    en.wikipedia.org/wiki/Personal_health_record

    The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.

  8. Case report form - Wikipedia

    en.wikipedia.org/wiki/Case_report_form

    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 ...

  9. Electronic prescribing - Wikipedia

    en.wikipedia.org/wiki/Electronic_prescribing

    Electronic prescription ( e-prescribing or e-Rx) is the computer-based electronic generation, transmission, and filling of a medical prescription, taking the place of paper and faxed prescriptions. E-prescribing allows a physician, physician assistant, pharmacist, or nurse practitioner to use digital prescription software to electronically ...

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