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A medical certificate or doctor's certificate[1][2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [3] It can serve as a sick note (UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition.
Functional capacity evaluation. A functional capacity evaluation (FCE) is a set of tests, practices and observations that are combined to determine the ability of the evaluated person to function in a variety of circumstances, most often employment, in an objective manner. Physicians change diagnoses based on FCEs. [1]
Attending physician statement. 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. In traditional underwriting, an APS is one of the most frequently ordered additional sources of medical background information.
It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting. [citation needed][1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician -recommended return, or other reason for a medical encounter. [2]
The terms EHR, electronic patient record (EPR) and EMR have often been used interchangeably, but differences between the models are now being defined. The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient 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 ...