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An FD-1023 (CHS Reporting Document) is the form FBI agents use to record raw, unverified reporting from confidential human sources. FD-1023s merely document that information; they do not reflect the conclusions of investigators based on a fuller context or understanding. Recording this information does not validate it, establish its credibility ...
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 ...
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 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 created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [ 6][ 7] In contrast, a ...
A medical certificate or doctor's certificate[ 1][ 2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [ 3] It can serve as a sick note ( UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition.
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 ...
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 ...
Informed consent is a principle in medical ethics, medical law, media studies, and other fields, that a person must have sufficient information and understanding before making decisions about accepting risk, such as their medical care. Pertinent information may include risks and benefits of treatments, alternative treatments, the patient's role ...
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