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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 ...
Consolidated Clinical Document Architecture. The HL7 Consolidated Clinical Document Architecture ( C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1] [2] [3] All certified Electronic health ...
Definition. A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or ...
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Pertaining file extensions include: .docx – Word document. .docm – Word macro-enabled document; same as docx, but may contain macros and scripts. .dotx – Word template. .dotm – Word macro-enabled template; same as dotx, but may contain macros and scripts. Other formats. .pdf – PDF documents. .wll – Word add-in. .wwl – Word add-in.
POLST ( Physician Orders for Life-Sustaining Treatment) is an approach to improving end-of-life care in the United States, encouraging providers to speak with the severely ill and create specific medical orders to be honored by health care workers during a medical crisis. [ 1] POLST began in Oregon in 1991 and currently exists in 46 states ...
Radiation treatment planning. In radiotherapy, radiation treatment planning ( RTP) is the process in which a team consisting of radiation oncologists, radiation therapist, medical physicists and medical dosimetrists plan the appropriate external beam radiotherapy or internal brachytherapy treatment technique for a patient with cancer .
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 ...