Medical Terminology for Health Care Professionals, 9e
https://content.grantham.edu/academics/GU_HP114/HP…The electronic health record (EHR) is an electronic record of health-related information for an individual. The EHR contains patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, radiology images, and personal data.
Progress note - Wikipedia
https://en.wikipedia.org/wiki/Progress_noteProgress 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. Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to rec…
Ortho Writes Perfect SOAP Note, First No-Worder This Year ...
gomerblog.com/2014/12/soap-noteLOS ANGELES, CA – Cliff Kershaw of UCLA Medical Center etched his way into the record books early this morning as he wrote the fiscal year’s first perfect note.The southpaw orthopedic surgeon not only defeated his patient’s left femoral neck fracture with a successful operation free of complications, but also completed his medical progress note without the use of words, …