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  2. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    The treatment plan may then include further investigations to clarify the diagnosis. The method by which doctors gather information about a patient's past and present medical condition in order to make informed clinical decisions is called the history and physical (a.k.a. the H&P). The history requires that a clinician be skilled in asking ...

  3. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    [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] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]

  4. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor or other clinician. Information on the nature and duration of the problem will be explored. History of the present illness A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical ...

  6. Medical diagnosis - Wikipedia

    en.wikipedia.org/wiki/Medical_diagnosis

    For example, a definitive diagnosis of cancer is made via tissue examination by a pathologist. [citation needed] Principal diagnosis The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. Many patients have additional diagnoses. [citation needed] Admitting diagnosis

  7. History of the present illness - Wikipedia

    en.wikipedia.org/wiki/History_of_the_present_illness

    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).

  8. 'Dr. Google' meets its match: Dr. ChatGPT - AOL

    www.aol.com/news/dr-google-meets-match-dr...

    As a fourth-year ophthalmology resident at Emory University School of Medicine, Dr. Riley Lyons’ biggest responsibilities include triage: When a patient comes in with an eye-related complaint ...

  9. Medical findings - Wikipedia

    en.wikipedia.org/wiki/Medical_findings

    Medical findings are the collective physical and psychological occurrences of patients surveyed by a medical doctor. The survey is composed of physical examinations by the doctor's senses and simple medical devices, which build clinical findings.