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  2. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The plan is what the health care provider will do to treat the patient's concerns—such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. [14] The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters.

  3. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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 ...

  4. Medication Administration Record - Wikipedia

    en.wikipedia.org/wiki/Medication_Administration...

    A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...

  5. Medication therapy management - Wikipedia

    en.wikipedia.org/wiki/Medication_therapy_management

    Medication therapy management, generally called medicine use review in the United Kingdom, is a service provided typically by pharmacists, medical affairs, and RWE scientists that aims to improve outcomes by helping people to better understand their health conditions and the medications used to manage them. [1]

  6. Personal health record - Wikipedia

    en.wikipedia.org/wiki/Personal_health_record

    The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.

  7. List of medical symptoms - Wikipedia

    en.wikipedia.org/wiki/List_of_medical_symptoms

    List of medical symptoms. Medical symptoms refer to the manifestations or indications of a disease or condition, perceived and complained about by the patient. [1] [2] Patients observe these symptoms and seek medical advice from healthcare professionals.

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  9. Past medical history - Wikipedia

    en.wikipedia.org/wiki/Past_Medical_History

    Current medications: note name, dosage, frequency of any medication, including any over-the-counter medications and herbal remedies. Note whether patient is taking ...