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23 relations: Admission note, Appendectomy, Clinical formulation, Differential diagnosis, Electronic health record, Emergency department, Emergency medical technician, F. A. Davis Company, Headache, Irish Journal of Medical Science, John Wiley & Sons, Kaiser Permanente, Laparoscopy, Lawrence Weed, Medical billing, Medical record, OPQRST, Patient, Pearson plc, Physical examination, SAMPLE history, Springer Publishing, Symptom.
Admission note
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
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Appendectomy
An appendectomy (known outside the United States as appendisectomy or appendicectomy) is a surgical operation in which the vermiform appendix (a portion of the intestine) is removed.
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Clinical formulation
A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment.
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Differential diagnosis
In medicine, a differential diagnosis is the distinguishing of a particular disease or condition from others that present similar clinical features.
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Electronic health record
An electronic health record (EHR), or electronic medical record (EMR), is the systematized collection of patient and population electronically-stored health information in a digital format.
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Emergency department
An emergency department (ED), also known as an accident & emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance.
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Emergency medical technician
Emergency medical technician (EMT) and ambulance technician are terms used in some countries to denote a health care provider of emergency medical services.
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F. A. Davis Company
F.A. Davis Company (F.A. Davis or Davis) is a publishing firm headquartered in Philadelphia, Pennsylvania, founded by F. A. Davis (1850–1917).
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Headache
Headache is the symptom of pain anywhere in the region of the head or neck.
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Irish Journal of Medical Science
The Irish Journal of Medical Science is a quarterly peer-reviewed medical journal that was established in 1832 by Robert Kane as the Dublin Journal of Medical & Chemical Science.
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John Wiley & Sons
John Wiley & Sons, Inc., also referred to as Wiley, is a global publishing company that specializes in academic publishing.
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Kaiser Permanente
Kaiser Permanente (KP) is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield.
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Laparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions (usually 0.5–1.5 cm) with the aid of a camera.
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Lawrence Weed
Lawrence Leonard "Larry" Weed (December 26, 1923 – June 3, 2017) was an American physician, researcher, educator, entrepreneur and author, who is best known for creating the problem-oriented medical record as well as one of the first electronic health records.
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Medical billing
Medical billing is a payment practice within the United States health system.
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Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.
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OPQRST
OPQRST is an mnemonic used by medical professionals to accurately discern reasons for a patient's symptoms and history in the event of an acute illness.
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Patient
A patient is any recipient of health care services.
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Pearson plc
Pearson plc is a British multinational publishing and education company headquartered in London.
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Physical examination
A physical examination, medical examination, or clinical examination (more popularly known as a check-up) is the process by which a medical professional investigates the body of a patient for signs of disease.
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SAMPLE history
SAMPLE history is an mnemonic acronym to remember key questions for a person's medical assessment.
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Springer Publishing
Springer Publishing is an American publishing company of academic journals and books, focusing on the fields of nursing, gerontology, psychology, social work, counseling, public health, and rehabilitation (neuropsychology).
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Symptom
A symptom (from Greek σύμπτωμα, "accident, misfortune, that which befalls", from συμπίπτω, "I befall", from συν- "together, with" and πίπτω, "I fall") is a departure from normal function or feeling which is noticed by a patient, reflecting the presence of an unusual state, or of a disease.
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Redirects here:
SOAP notes, Subjective Objective Assessment Plan.
References
[1] https://en.wikipedia.org/wiki/SOAP_note
