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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.
Medical state. Medical state is a term used to describe a hospital patient 's health status, or condition. The term is most commonly used in information given to the news media, and is rarely used as a clinical description by physicians . Two aspects of the patient's state may be reported. The first aspect is the patient's current state, which ...
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 ...
A case series in which the patients receive treatment in a clinic or other medical facility. (NCI) Clinical study or Clinical trial. A type of research study that tests how well new medical approaches work in people. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease.
Response evaluation criteria in solid tumors ( RECIST) is a set of published rules that define when tumors in cancer patients improve ("respond"), stay the same ("stabilize"), or worsen ("progress") during treatment. The criteria were published in February 2000 by an international collaboration including the European Organisation for Research ...
In a medical encounter, a past medical history (abbreviated PMH) is the total sum of a patient's health status prior to the presenting problem. Questions to include [ edit ] Different sources include different questions to be asked while conducting a PMH, but in general, they include the following:
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
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 ...