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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]
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.
An attending physician statement (APS) is a report by a physician, hospital, or medical facility that has treated, or is currently treating, a person seeking insurance. [1] In traditional underwriting, an APS is one of the most frequently ordered additional sources of medical background information. The APS is one of the more expensive ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
The most recent medical report publicly shared by Trump was featured in a Nov. 20, 2023, Truth Social post, which included a screenshot of a letter from Dr. Bruce Aronwald, sharing little detail ...