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2. 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 ...

3. Review of systems - Wikipedia

   en.wikipedia.org/wiki/Review_of_systems

   A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).

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. 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.

6. 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 ...

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. Clinical peer review - Wikipedia

   en.wikipedia.org/wiki/Clinical_peer_review

   Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. [1][2] A discipline-specific process may be referenced accordingly (e.g., physician peer review, nursing peer review). Today, clinical peer review is most ...

9. Human subject research - Wikipedia

   en.wikipedia.org/wiki/Human_subject_research

   Medical human subject research often involves analysis of biological specimens, epidemiological and behavioral studies and medical chart review studies. [1] A specific, and especially heavily regulated, type of medical human subject research is the " clinical trial ", in which drugs, vaccines and medical devices are evaluated.)