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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.
Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other members of the medical care team, and allow retrospective review of case details for a variety of interested parties.
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It is one of three types of literature reviews frequently used in epidemiology, along with meta-analysis and traditional narrative reviews. Pooled analyses may be either retrospective or prospective. [1] It is often used when the results of individual studies do not allow for a firm conclusion to be drawn. [2]
The term retrospective diagnosis is also sometimes used by a clinical pathologist to describe a medical diagnosis in a person made some time after the original illness has resolved or after death. In such cases, analysis of a physical specimen may yield a confident medical diagnosis.
The first studies that used newer methods were retrospective chart reviews done in a hospital by a doctor or nurse. These studies used several different methods to identify and document injuries, such as direct visualization, colposcopy, and/or tissue staining dyes. Earlier studies only used direct visualization for their data. [1]
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
Medical human subject research often involves analysis of biological specimens, epidemiological and behavioral studies and medical chart review studies. [1] A specific, and especially heavily regulated, type of medical human subject research is the " clinical trial ", in which drugs, vaccines and medical devices are evaluated.)
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