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  2. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    It provides information for the continuation of care following discharge. [10] History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. [11] Operative Note - The Operative Note is created immediately following a surgical or other high-risk procedure.

  3. Continuity of Care Document - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Document

    The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA) standard. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing).

  4. Maintenance of Certification - Wikipedia

    en.wikipedia.org/wiki/Maintenance_of_Certification

    Considering a recent meta-analysis that shows a decline in physician performance associated with the time elapsed since the physician's initial training, [11] it is essential for physicians to participate in programs such as Maintenance of Certification in order to keep current with medicine's expanding knowledge base and technical advances ...

  5. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...

  6. National Board of Medical Examiners - Wikipedia

    en.wikipedia.org/wiki/National_Board_of_Medical...

    The National Board of Medical Examiners (NBME), founded in 1915, is a United States non-profit which develops and manages assessments of student physicians. Known for its role in developing the United States Medical Licensing Examination (USMLE) in partnership with the Federation of State Medical Boards (FSMB), USMLE examinations for medical students and residents are used by medical licensing ...

  7. 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 ...

  8. Physical examination - Wikipedia

    en.wikipedia.org/wiki/Physical_examination

    The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.

  9. 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 ...

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