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That acronym can be pronounced as 'soap' but reminds us that we will be formulating with clinical hypotheses instead of plugging in a simple diagnostic label. Kettenbach, Ginge; Schlomer, Sarah L. (2016) [1990]. Writing patient/client notes: ensuring accuracy in documentation (5th ed.). F. A. Davis Company. ISBN 9780803638204. OCLC 934020211.
Veterinary Record, branded as Vet Record, is a semi-monthly peer-reviewed medical journal covering the field of veterinary medicine. It is published by Wiley on behalf of the British Veterinary Association and is distributed to its members as part of their membership. It was established in 1888.
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 ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
The Merck Veterinary Manual was first published in 1955. [1] It was based on the Merck Manual of Diagnosis and Therapy , which was first published in 1899 as a reference for physicians. [ 1 ] The first edition of the Veterinary Manual included contributions from over 200 authors, with 389 chapters divided into sections on public health ...
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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
In UK veterinary practice, the replacement of paper recording systems with electronic methods of storing animal patient information escalated from the 1980s and the majority of clinics now use electronic medical records. In a sample of 129 veterinary practices, 89% used a Practice Management System (PMS) for data recording. [150]
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...