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• Documentation
  == Documentation (Medicine) == ...eld of medicine refers to the systematic recording of patient information, medical history, clinical findings, diagnostic test results, therapies, and other h
  2 KB (298 words) - 04:47, 7 February 2024
• Clinical documentation improvement
  == Clinical Documentation Improvement == '''Clinical Documentation Improvement''' (''pronunciation: klin-i-kəl dä-kyü-mən-'tā-shən im-'p
  3 KB (349 words) - 22:02, 13 February 2024
• Systematized Nomenclature of Medicine
  ...ges, that provides codes, terms, synonyms and definitions used in clinical documentation and reporting. SNOMED is considered to be the most comprehensive, multiling * [[Clinical Terms]]: Clinical terms are the specific terms used in clinical documentation and reporting. They are a key component of SNOMED.
  2 KB (215 words) - 21:42, 14 February 2024
• Amend
  ...rds. It refers to the process of making changes or corrections to existing medical records, often to ensure accuracy and completeness of information. ...refer to the act of making something right or accurate. In the context of medical records, it refers to the process of rectifying errors or inaccuracies.
  2 KB (270 words) - 21:52, 3 February 2024
• Reporting
  ...ematic documentation of patient health information, clinical findings, and medical procedures. It is a crucial aspect of healthcare delivery, facilitating com ...rived from the Latin word 'reportare', which means 'to bring back'. In the medical context, it signifies the process of bringing back or conveying information
  2 KB (275 words) - 22:59, 5 February 2024
• Medical photography
  == Medical photography == ...tions, procedures, and medical devices. It is used extensively in clinical documentation, research, and education.
  2 KB (269 words) - 04:19, 11 February 2024
• Table
  === In Medical Documentation === In medical documentation, a '''table''' is a means of arranging data in rows and columns. The use of
  2 KB (248 words) - 06:31, 4 February 2024
• Note
  ...tion, observations, and treatment plans. It is a crucial part of [[medical documentation]] and [[patient care]]. ...originates from the Latin word 'nota', which means a mark or sign. In the medical context, it signifies a written record or sign of a patient's health status
  2 KB (253 words) - 21:11, 3 February 2024
• Recorded
  '''Recorded''' (pronounced: /rɪˈkɔːrdɪd/) is a term used in the medical field to denote the act of documenting or preserving information, particula * [[Electronic Health Record]] (EHR): An electronic version of a patient's medical history, maintained by the provider over time, and may include all of the k
  2 KB (222 words) - 14:07, 5 February 2024
• Text
  ...er to the written or printed words that form the main body of content in a medical document, book, or other material. == Medical Usage ==
  2 KB (240 words) - 21:54, 3 February 2024
• SOAP note
  ...onym for '''Subjective, Objective, Assessment, and Plan''') is a method of documentation employed by healthcare providers to write out notes in a patient's chart, a ...coined in the 1960s by Dr. Lawrence Weed as part of the [[Problem Oriented Medical Record]] (POMR) system. The acronym stands for Subjective, Objective, Asses
  2 KB (227 words) - 03:49, 8 February 2024
• Address
  ...often used in the context of healthcare delivery, patient navigation, and medical record keeping. ...it has been adapted to refer to the specific location or destination of a medical service or procedure.
  1 KB (137 words) - 21:17, 4 February 2024
• Medical Record (journal)
  == Medical Record (journal) == ...us fields of [[medicine]]. It is a comprehensive source of information for medical professionals, researchers, and students.
  1 KB (166 words) - 02:18, 12 February 2024
• Annotation
  ...medicine refers to the process of adding notes or comments to a patient's medical record for the purpose of clarification, explanation, or additional informa * [[Electronic Health Record (EHR)]]: An electronic version of a patient's medical history, that is maintained by the provider over time, and may include all
  1 KB (177 words) - 22:56, 5 February 2024
• Progress note
  ...'[[Medical Record]]''': A comprehensive document that includes a patient's medical history, including diagnoses, treatment plans, progress notes, and more. * '''[[SOAP Note]]''': A method of documentation employed by healthcare providers to write out notes in a patient's chart, a
  2 KB (273 words) - 23:56, 8 February 2024
• Burns Archive
  ...MD, in 1977. The archive is renowned for its extensive collection of early medical photography, dating back to the mid-19th century. ...of the clinical presentation of patients, medical and surgical procedures, medical devices and specimens from autopsy.
  2 KB (205 words) - 22:48, 8 February 2024
• File
  * [[Electronic Health Record]]: An electronic version of a patient's medical history, including all treatments, tests, and diagnoses. * [[Medical Record]]: A systematic documentation of a patient's medical history and care.
  2 KB (207 words) - 21:34, 3 February 2024
• Rape kit
  ...egation of sexual assault. The kit contains tools such as swabs, bags, and documentation forms. * [[Documentation form]]s for recording the examination, detailing the assault, and maintaini
  2 KB (271 words) - 03:52, 8 February 2024
• Logging
  ...ording medical information, such as patient symptoms, treatment plans, and medical histories. The term is derived from the word "log", which in its original c ...ing a "log book" where they would record details about their journey. In a medical context, logging refers to the systematic recording of patient information
  2 KB (215 words) - 01:38, 5 February 2024
• Templates
  ...in [[surgical procedures]] as guides for cutting or shaping. In [[medical documentation]], templates are used to standardize the format and content of patient reco ...visual representations of the interior of a body for clinical analysis and medical intervention.
  1 KB (201 words) - 23:19, 5 February 2024

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