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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 ...
Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. 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 ...
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 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 ...
A Gantt chart is a type of bar chart [4] [5] that illustrates a project schedule. [6] This chart lists the tasks to be performed on the vertical axis, and time intervals on the horizontal axis. [4] [7] The width of the horizontal bars in the graph shows the duration of each activity. [7] [8] Gantt charts illustrate the start and finish dates of ...
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 ...
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]
In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases.
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