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For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
The primary use case for the CCD is to provide a snapshot in time containing the germane clinical, demographic, and administrative data for a specific patient. [8] Diagnostic Imaging Report - A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist's interpretation of image data. [9]
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.
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. [ 17 ]
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