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  2. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes , preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record.

  3. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    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. Progress ...

  4. Medical diagnosis - Wikipedia

    en.wikipedia.org/wiki/Medical_diagnosis

    Lag time due to delays in reading x-rays have been cited as a major challenge in care delivery. The Department of Health and Human Services has reportedly found that interpretation of x-rays is rarely available to emergency room physicians prior to patient discharge. [15] Long lag times are often called "diagnostic odyssey".

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  6. SAMPLE history - Wikipedia

    en.wikipedia.org/wiki/SAMPLE_History

    It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]

  7. List of medical abbreviations: P - Wikipedia

    en.wikipedia.org/wiki/List_of_medical...

    patient (from Latin patiens, meaning "one who endures" or "one who suffers") PTA: percutaneous transluminal angioplasty post-traumatic amnesia prior to admission Peritonsillar abscess PTB: pulmonary tuberculosis: PTC: percutaneous transhepatic cholangiography: PTCA: percutaneous transluminal coronary angioplasty: PTD: prior to discharge preterm ...

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