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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 ...
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
Further template category notes. This category contains pages in the template namespace. It should not be used to categorize articles or pages in other namespaces. To add a template to this category: If the template has a separate documentation page (usually called "Template: template name /doc"), add. [[Category:Medical symptoms and signs ...
To change this template's initial visibility, the |state= parameter may be used: {{Medical records and physical exam|state= collapsed }} will show the template collapsed, i.e. hidden apart from its title bar. {{Medical records and physical exam|state= expanded }} will show the template expanded, i.e. fully visible. Editors can experiment in ...
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 ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
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