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2. SOAP note - Wikipedia

   en.wikipedia.org/wiki/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 workflow ...

3. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...

4. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other members of the medical care team, and allow retrospective review of case details for a variety of interested parties. They are the repository of medical facts and clinical thinking, and are ...

5. Point of care - Wikipedia

   en.wikipedia.org/wiki/Point_of_care

   Documentation performed at the time of clinical point of care can be conducted using paper or electronic formats. This process aims to capture medical information pertaining to patient's healthcare needs. The patient's health record is a legal document that contains details regarding patient's care and progress. [3] The types of information captured during the clinical point of care ...

6. Personal health record - Wikipedia

   en.wikipedia.org/wiki/Personal_health_record

   A personal health record ( PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims. The intention of ...

7. Nursing care plan - Wikipedia

   en.wikipedia.org/wiki/Nursing_care_plan

   A nursing care plan provides direction on the type of nursing care the individual/family/community may need. [1] The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. [2] Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the ...