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The HL7 Consolidated Clinical Document Architecture ( C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1] [2] [3] All certified Electronic health records in the United States are required to ...
A technical report (also scientific report) is a document that describes the process, progress, or results of technical or scientific research or the state of a technical or scientific research problem. [1] [2] It might also include recommendations and conclusions of the research. Unlike other scientific literature, such as scientific journals ...
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.
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 ...
A working paper or technical paper. This encompasses literature that has not been peer reviewed or published in an academic journal. [1] Working papers may be disseminated for the purpose of receiving feedback to improve the publication. [2] They are often the basis for related works, and may in themselves be cited by peer-review papers.
Quad chart. A quad chart is a form of technical documentation used to briefly describe an invention or other innovation through writing, illustration and/or photographs. [1] Such documents are described as "quad" charts because they are divided into four quadrants laid out on a landscape perspective. [2] [3] [4] They are typically one-page only ...
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 ...
Report. A report is a document or a statement that presents information in an organized format for a specific audience and purpose. Although summaries of reports may be delivered orally, complete reports are usually given in the form of written documents. [1] [2] Typically reports relay information that was found or observed. [2]